RDbSO 


So  8 


Columbia  Untoersrttp 
in  tfje  Cttp  of  i^eto  ^orfe 


department  of  Hmrgerp 
Pull  memorial  funo 


TECHNIQUE  OF  OPERATIONS  ON  THE  BONES, 
JOINTS,  MUSCLES  AND  TENDONS 


THE  MACMILLAN  COMPANY 

NEW   YORK    •    BOSTON   •    CHICAGO    ■   DALUS 
ATLANTA    •    SAN  FRANCISCO 

MACMILLAN  &  CO.,  Limited 

LONDON   •   BOMBAY    •  CALCUTTA 
MELBOURNE 

THE  MACMILLAN  CO.  OF  CANADA,  Ltd. 

TORONTO 


TECHNIQUE  OF  OPERATIONS 


ON  THE 


BONES,  JOINTS,  MUSCLES  AND  TENDONS 


BY 

ROBERT  SOUTTER 

a.b.,  m.d.  (harvard) 

assistant  surgeon  to  the  children's  hospital,  boston;  surgeon-in-chief  to 

the  house  of  the  good  samaritan;  surgeon  to  the  long  island  hospital, 

boston;  surgeon    to  the    Massachusetts    state    hospital,    canton; 

surgeon  to  the  peabody  home;  instructor,  harvard  university 

medical  school;  fellow  of  american  college  of  surgeons, 

american    medical    association,    american    orthopedic 

association,    boston    surgical    society,   etc. 


$>w  fnrk 

THE   MACMILLAN   COMPANY 

1917 

All  rights  reserved 


Copyright,   1917 

By  THE  MACMILLAN  COMPANY 

Set  up  and  electrotyped.     Published  September,  1917. 


Wo 

DR.  E.  H.  BRADFORD 

Professor  of  Orthopedic  Surgery,  and  Dean,  Harvard  University  Medical  School 

THIS  VOLUME  IS  DEDICATED  AS  A  TOKEN  OF  APPRECIATION 
OF  HIS  CLEAR-MINDED  JUDGMENT,  HIS  HIGH  SURGICAL 
SKILL  AND  PROFESSIONAL  IDEALS,  ALL  OF  WHICH  HAVE  BEEN 
A  CONSTANT  SOURCE  OF  INSPIRATION  DURING  THE  INTI- 
MATE ASSOCIATION  OF  FIFTEEN  YEARS  PARTNERSHIP. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/techniqueofoperaOOsout 


PREFACE 

This  volume  has  been  written  at  the  request  of  many  of  my  graduate 
students,  including  surgeons  who  have  taken  the  courses  at  Harvard 
University  Medical  School  and  internes  in  the  hospitals  with  which  I  am 
connected. 

The  work  contains  only  carefully  tried-out  methods  which  cover 
operations  on  the  bones,  joints,  muscles  and  tendons,  including  muscle 
transplantations  together  with  all  the  common  operations  for  the  cor- 
rection of  deformities  and  some  of  the  less  usual  ones.  It  is  intended  as  a 
practical  guide  for  advanced  students,  and  for  the  surgeon  who  desires 
to  select  one  of  several  tried-out  methods  for  any  special  case. 

I  have  endeavored  to  give  the  important  details  of  all  procedures  in 
order  to  freshen  the  surgeon's  memory  before  operating.  The  history 
and  origin  of  the  operations  is  omitted  for  the  sake  of  brevity.  An  at- 
tempt is  made  to  give  the  more  useful  rather  than  to  enumerate  all 
operations  that  can  be  done.  I  have  not  planned  to  compile  an  ency- 
clopedia but  to  present  a  ready  reference  for  the  technique  of  the  more 
practical  operations  on  the  upper  and  lower  extremeties. 

The  operative  procedures,  useful  in  infantile  paralysis,  are  dealt  with 
at  length  and  the  tried-out  methods  are  here  recommended  rather  than 
every  possible  operation. 


vu 


CONTENTS 

PART  I— HIP 
CHAPTER  I 

HIP   OPERATIONS   FOR   CONGENITAL   DEFORMITIES 

1.  Dislocation  of  the  hip.  Manipulation.    Bloodless  reduction. 

2.  Dislocation  of  the  hip.  Dr.  Bradford's  hip  machine. 

3.  Dislocation  of  the  hip.  Post  operative  treatment. 

4.  Dislocation  of  the  hip.  Open  operation. 

5.  Dislocation  of  the  hip.  Plaster  of  Paris. 

CHAPTER  II 

HIP  MUSCLE  AND  TENDON  OPERATIONS.     MUSCLE  AND  TENDON  TRANSPLANTATION 

6.  Contracted  soft  tissues.    Hip  flexion. 

7.  Manipulation  of  the  hip. 

8.  Transplantation  of  the  hip  flexors  at  the  ilium.    Fasciotomy  at  the  hip.* 

9.  Fasciotomy  to  relieve  flexion  and  abduction  of  the  hip. 

10.  Application  of  plaster  of  Paris  after  fasciotomy  or  after  osteotomy  of  the 

femur. 

CHAPTER  III 

OTHER  OPERATIONS  IN  CASES  OF  PARTIAL  OR  TOTAL  PARALYSIS  ABOUT  THE  HIP 

11.  Flail  hip. 

12.  Operation  for  arthrodesis  of  the  hip  in  paralytic  conditions  and  in  painful 

osteo-arthritic  conditions. 

13.  Silk  ligament  at  the  hip  for  paralysis  of  the  abductors. 

CHAPTER  IV 

INCISION,    PUNCTURE,    ARTHROTOMY   AT   THE   HIP 

14.  Incision  for  exposure  of  the  ilium,  Sprengel's  incision. 

15.  Incision  for  exposure  of  the  sacro-iliac  joint. 

16.  Arthrotomy. 

17.  Arthrotomy  of  the  hip. 

18.  Anterior  incision. 

19.  Antero-lateral  incision. 

20.  Antero-lateral  incision  with  second  part  when  more  room  is  necessary. 

21.  Posterior  incision. 

22.  U-shaped  incision,  Murphy,  for  arthroplasty. 

23.  Anterior  U  incision,  Brackett. 

24.  Internal  lateral  incision.    Adductor  incision  for  the  hip. 

*  Soutter  operation. 
ix 


K  CONTENTS 

25.  Arthrotomy  for  fractures  about  the  hip. 

26.  A  method  of  treating  overlapping  fractures. 

27.  Fractures  of  lung  standing  still  ununited  or  united  with  deformity  prevent- 

ing function. 

28.  Fracture  of  the  neck  of  the  femur  in  the  young  or  middle-aged. 

29.  Operation  for  Coxa  vara. 

30.  Incision  for  exposure  of  the  sciatic  nerve. 

31.  Incision  for  the  adductor  magnus  tendon  in  hip  operations. 

32.  Incision  for  gluteal  bursitis. 

33.  Tapping  the  hip  joint. 

CHAPTER  V 

OPERATIVE   TREATMENT   IN    CASE    OF   HIP-JOINT   ANKYLOSIS 

34.  Principle  of  arthroplasty. 

35.  Arthroplasty  at  the  hip  operation. 

36.  Operation  for  deformity  at  the  hip  with  ankylosis.    Hip  flexion  and  adduc- 

tion with  or  without  dislocation  of  the  hip. 

37.  Subtrochanteric  osteotomy,  "Gant." 

38.  Operation  for  coxa  vara  with  ankylosis  of  the  hip. 

39.  Osteotomy  at  the  neck  of  the  femur. 

40.  Albee  hip  operation  in  osteo-arthritis.    Arthrodesis. 

41.  Operation  for  separation  of  the  epiphysis  at  the  hip  (see  also  fractures  of 

the  neck). 

42.  Adjusting  legs  of  unequal  length. 

CHAPTER  VI 

OPERATIONS  IN   SUPPURATIVE   CONDITIONS  ABOUT  THE  HIP 

43.  Suppurative  conditions  about  the  hip. 

44.  Excisions  of  the  hip  in  suppurative  conditions. 

45.  Methods  and  principles  of  drainage  in  acute  non-tubercular  suppurative 

joint  disease. 

46.  Acute  arthritis  of  infancy. 

47.  Osteomylitis. 

PART  II— KNEE 
CHAPTER  I 

OPERATIONS  FOR  DEFORMITIES  OF  THE   KNEE 

48.  Operative  manipulation  of  the  knee. 

49.  Operation  for  flexion  deformity  of  the  knee. 

50.  Operation  of  tendon  lengthening  to  correct  knee  flexion. 

51.  Correction  of  subluxation  of  the  tibia  by  manipulation,  genuclasis. 

52.  Another  method  of  correcting  subluxation. 

53.  Operation  for  knock  knee  and  bow  leg. 

54.  Correction  of  flexion  deformity  of  the  knee  by  osteotomy  of  the  femur. 

55.  Technique  of  osteotomy  of  the  femur  for  flexion  deformity  of  the  knee. 

McCewen  operation. 


CONTENTS  xi 

56.  The  application  of  plaster  of  Paris  bandage  after  operation  or  manipulation 

of  the  knee. 

57.  Plaster  of  Paris  for  holding  the  knee. 

58.  A  simple  method  for  preventing  rotation  of  a  leg  plaster. 

59.  Osgood  operation  for  flexion  deformity  at  the  knee. 

CHAPTER  II 

MUSCLE  AND  TENDON  OPERATIONS.      MUSCLE  AND  TENDON  TRANSPLANTATIONS 

60.  Operation  for  rupture  of  the  quadriceps  extensor. 

61.  Muscle  transplantation  for  paralysis  of  the  anterior  thigh  muscles. 

62.  Transplantation  of  two  hamstrings  forward. 

63.  Operation  for  transplantation  of  the  sartorius  muscle  for  a  weak  or  para- 

lyzed quadriceps. 

64.  Transplantation  of  the  tensor  fascia  femoris  to  a  weak  or  paralyzed  quad- 

riceps. 

65.  Transplantation  of  the  external  hamstrings  forward  for  a  weak  or  paralyzed 

quadriceps. 

66.  Technique  of  muscle  transplantation. 

67.  Muscle  transplantation  for  paralysis  of  the  anterior  thigh  muscles. 

68.  Plaster  of  Paris  bandage  following  transplantation  in  the  thigh. 

69.  Myotomy  of  the  adductors  and  hamstring  muscles  for  contracted  muscles. 

70.  Operation  for  tenotomy  of  the  hamstrings;  tendon  lengthening. 

71.  Myotomy  in  spastic  paralysis. 

72.  Operation  for  myotomy  of  the  internal  hamstring. 

73.  Operation  for  removing  a  section  from  a  muscle. 

74.  Operation  for  tenotomy  of  the  adductor  magnus  tendon. 

CHAPTER  III 

OPERATION   IN   CASES   OF   PARTIAL   AND   TOTAL   PARALYSIS   ABOUT   JOINTS 

75.  Arthrodesis  at  the  knee. 

76.  Operation  for  flail  condition  of  the  knee. 

77.  Bartow  silk  ligaments  at  the  knee. 

CHAPTER  IV 

INCISION,   PUNCTURES  AND  ARTHROTOMY 

78.  Operation  for  a  displaced  semilunar  cartilage. 

79.  Operation  for  torn  crucial  ligament. 

80.  Arthrotomy. 

81.  Arthrotomy  at  the  knee. 

82.  Anterior  median  incision.    Splitting  the  patella  into  lateral  halves. 

83.  Posterior  incision. 

84.  The  bayonet  incision  at  the  knee. 

85.  Two  lateral  incisions  at  the  knee. 

86.  The  U-shaped  incision  at  the  knee. 

87.  Arthrotomy  for  fractures  about  the  joints. 

88.  A  method  of  treating  overlapping  fractures. 


xii  CONTENTS 

89.  Fractures  of  long  standing  still  ununited  or  united  with  deformity  pre- 

venting function. 

90.  Fracture  of  the  patella. 

91.  Fractures  into  the  knee  joint. 

92.  Operation  for  dislocation  of  the  patella. 

93.  Tapping  the  knee  joint. 

CHAPTER  V 

SUPPURATIVE   TREATMENT  IN   CASES   OF  JOINT  ANKLYOSIS 

94.  Excision  of  the  knee  for  ankylosis. 

95.  Arthroplasty  for  ankylosis  of  the  knee. 

CHAPTER  VI 

OPERATION   IN   SUPPURATIVE   CONDITIONS 

96.  Suppurative  conditions  at  the  knee. 

97.  Osteomyelitis. 

98.  Excision  of  the  knee  in  suppurative  conditions. 

98a.  Methods  and  principles  of  drainage  in  acute  non-tubercular  suppurative 
joint  disease.    Knee,  femur,  tibia. 

PART  III— FOOT  AND  ANKLE 
CHAPTER  I 

OPERATION  FOR  DEFORMITIES 

99.  Manipulating  the  foot. 

100.  Manipulating  the  foot  by  means  of  apparatus. 

101.  Manipulating  the  foot  by  means  of  the  Thomas  Wrench. 

102.  Manipulating  the  foot  by  means  of  the  Bradford  Wrench. 

103.  Manipulating  the  foot  by  means  of  the  Davis  Wrench. 

104.  Operation  for  talipes  varus  and  equino  varus  club  foot. 

105.  Operation  on  the  bone  for  extreme  varus  or  equino  varus  (club  foot  opera- 

tion) congenital  or  acquired. 

106.  Operation  for  equino  varus,  congenital  or  acquired.    Relieving  the  internal 

ligamentous  attachments  when  the  oscalsis  is  tilted.     Dr.   Ober's 
operation. 

107.  Application  of  plaster  for  varus  or  equino  varus,  club  foot  plaster. 

108.  The  after-treatment  of  equino  varus. 

109.  Operation  for  valgus,  equino  valgus,  and  calcaneo  valgus.    Flat  foot. 

110.  Extreme  valgus,  calcaneo  valgus,  and  equino  valgus. 

111.  Bone  operation  for  valgus,  equino  valgus  or  calcaneo  valgus. 

112.  Operation  for  valgus  with  marked  tilting  of  the  oscalcis. 

113.  Plaster  of  Paris  bandage  for  valgus. 

114.  Operation  for  arthrodesis  of  the  astragalo-scaphoid  joint  for  valgus,  foot 

strain,  and  partial  paralysis. 

115.  Operation  for  talipes  calcaneous. 


CONTENTS  xiii 

116.  Operation  for  pes  cavus. 

117.  Deformities  limiting  the  motion  of  the  ankle  joint  following  Potts  fracture. 

118.  Hammer  toe  operation.    Claw  foot. 

119.  Hammer  toe  and  claw  foot.    Contracted  extensor  longus  digitorum. 

120.  Hammer  toe  and  claw  foot.     Subcutaneous  tenotomy  of  extensor  longus 

digitorum  near  the  head  of  the  metatarsal. 

121.  Hammer  toe  and  claw  foot.    Tenotomy  of  the  extensor  longus  pollicis  near 

the  head  of  the  metatarsal.    Open  tenotomy. 

122.  Hammer  toe  and  claw  foot.    Operation  for  tenotomy  or  tendon  lengthen- 

ing of  the  extensor  longus  digitorum  tendon  in  the  leg. 

123.  Hammer  toe  and  claw  foot.    Operation  on  the  bone. 

124.  Hammer  toe  and  claw  foot.    Joint  excision. 

125.  Operation  for  hallux  valgus. 

CHAPTER  II 

MUSCLE   AND   TENDON   OPERATIONS.      MUSCLE   AND   TENDON   TRANSPLANTATION 

126.  General  principles  in  simple  tenotomies,  tendon  lengthening  and  tendon 

shortening. 

127.  Operation  for  tendon  lengthening. 

128.  Operation  for  subcutaneous  tenotomy  of  the  tendo  achilles. 

129.  Operation  for  talipes  equinus. 

130.  After-treatment. 

131.  The  plaster  of  Paris  bandage  for  the  foot  after  operation  for  talipes  equinus. 

132.  Operation  for  tenotomy  or  tendon  lengthening.     Subcutaneous  zig-zag 

tenotomy  of  the  tendo-achilles. 

133.  The  tenotome. 

134.  Operation  for  open  tenotomy  to  relieve  contracture  of  flexor  longus  digi- 

torum in  the  lower  leg. 

135.  Subcutaneous  tenotomy  of  the  flexor  longus  digitorum  at  the  base  of  the 

toes. 

136.  Subcutaneous  tenotomy  of  the  plantarfascia. 

137.  Operation  for  contracture  of  the  tibialis  posticus  in  the  leg. 

138.  Tenotomy  or  tendon  lengthening  of  the  peroneii  muscles. 

139.  Tenotomy  or  tendon  lengthening  of  the  tibialis  anticus. 

140.  Tenotomy  to  relieve  hammer  toe  (see  hammer  toe  operation). 

141.  Tenotomy  to  relieve  contracted  extensor  longus  digitorum  (see  description 

under  hammer  toe) . 

142.  Subcutaneous  tenotomy  of  extensor  longus  digitorum  near  the  head  of  the 

metatarsal  (see  under  hammer  toe) . 

143.  Different  forms  of  tenotomy  to  relieve  contracted  extensor  longus  digitorum 

in  the  lower  leg  (see  description  under  hammer  toe  operation) . 

144.  Operation  for  tendon  shortening. 

145.  Other  methods  of  tendon  shortening. 

146.  Operation  for  shortening  the  tendo  achilles. 

147.  Operation  for  shortening  the  extensor  longus  digitorum. 

148.  Operation  for  a  weak  or  paralysed  tibialis  anticus.    Transplantation  of  the 

peroneii  forward  to  give  dorsal  motion  to  the  foot.    Lange  method. 

149.  Plaster  of  Paris,  following  muscle  transplantation. 

150.  After-treatment, 


xiv  CONTENTS 

151.  Operation  for  a  weak  or  paralyzed  tibialis  anticus.    Transplantation  of  the 

tibialis  posticus  forward  to  give  dorsal  motion  to  the  foot. 

152.  Operation  for  a  weak  or  paralyzed  tibialis  anticus.    Transplantation  of  the 

flexor  longus  digitorum  to  give  dorsal  motion  to  the  foot. 

153.  Operation  for  a  weak  or  paralyzed  tibialis  anticus.     Transferring  the  ex- 

tensor longus  hallucis  to  reenforce  the  tibialis  anticus  in  the  lower 
third  of  the  leg. 

154.  Operation  for  a  weak  or  paralyzed  tibialis  anticus.    Transplantation  of  the 

extensor  longus  hallucis  to  the  tarsus. 

155.  Operation  for  a  weak  or  paralyzed  tibialis  anticus.     Transplantation  of 

the  extensor  longus  digitorum  to  the  tarsus. 

156.  Operation  for  a  weak  or  paralyzed  tibialis  anticus.     Transplantation  of 

the  extensor  longus  digitorum  to  the  tibialis  anticus  in  the  lower  third 
of  the  leg. 

157.  Operation  for  a  weak  or  paralyzed  tibialis  anticus.    Transplantation  of  the 

extensor  longus  hallucis  to  the  head  of  the  metatarsal. 

158.  Operation  for  a  weak  or  paralyzed  tibialis  anticus.    Transplantation  of  the 

extensor  longus  digitorum. 

159.  Operation  for  a  weak  or  paralyzed  tibialis  anticus.     Transplantation  of 

the  extensor  longus  digitorum  to  the  head  of  the  metatarsal  to  give 
power  to  raise  the  foot. 

160.  Operation  for  paralysis  of  the  tibialis  anticus.    Transplantation  of  one- 

half  of  the  tendo  achilles  forward. 

161.  Operation  for  partial  or  total  paralysis  of  the  peroneii.    Transplantation 

of  one-half  of  the  tendo  achilles  forward. 

162.  Operation  for  total  or  partial  paralysis  of  the  tibialis  posticus.    Transplan- 

tation of  one-half  of  the  tendo  achilles. 

163.  Operation  for  transplantation  of  the  flexor  longus  digitorum  for  partial 

paralysis  of  the  tendo  achilles. 
16-1.  Operation  for  transplantation  of  the  tibialis  posticus  for  partial  paralysis 
of  the  tendo  achilles. 

165.  Transplantation  of  peroneii  to  the  tendo  achilles. 

166.  Operation  for  paralysis  of  the  great  toe.    Transplantation  of  its  distal  end 

to  that  of  the  tibialis  anticus. 

167.  Operation  for  transplantation  of  the  tibialis  posticus  to  the  tendo  achilles. 

CHAPTER  III 

OPERATION  FOR  PARTIAL  AND  TOTAL  PARALYSIS  ABOUT  THE  ANKLE 

168.  Astragalectomy  and  displacement  of  the  foot  backward  for  a  flail  or  par- 

tially flail  ankle  or  foot. 

169.  After-treatment. 

170.  Application  of  a  plaster  of  Paris  following  an  astragalectomy. 

171.  Operation  for  insertion  of  silk  ligaments  at  the  ankle. 

172.  Silk  ligament  operation  at  the  ankle.    Open  method. 

173.  Silk  ligament  operation.    Bradford's  subcutaneous  method. 

174.  Tendon  fixation.    Galli. 

175.  Tendon  fixation  for  varus. 

176.  Tendon  fixation  for  valgus.    Dr.  Galli's  method. 

177.  Tendon  fixation  for  calcaneous.    Dr.  Galli's  method. 


CONTENTS  xv 

178.  Fascia  transplantation  for  toe  drop. 

179.  Arthrodesis  of  the  ankle  for  flail  conditions  at  the  ankle. 

CHAPTER  IV 

INCISION,   PUNCTURE   AND  ARTHROTOMY  AT  THE   ANKLE 

180.  Arthrotomy. 

181.  Anterior  external  incision. 

182.  Posterior  external  incision. 

183.  Anterior  internal  incision. 

184.  Posterior  internal  incision. 

185.  Anterior  median  incision. 

186.  Circular  incision  for  the  exposure  of  the  ankle  joint. 

187.  Arthrotomy  for  fracture  about  the  joints. 

188.  Osteotomy  for  deformity  of  the  leg. 

189.  A  method  of  treating  overlapping  fractures. 

190.  Fractures  of  long  standing  still  ununited  or  united  with  deformity  prevent- 

ing function. 

191.  Tapping  at  the  ankle. 

CHAPTER  V 

OPERATIVE   TREATMENT   IN    CASES    OF   JOINT   ANKYLOSIS 

192.  Arthroplasty  for  ankylosis  of  the  tibio  tarsal  joint. 

193.  Arthroplasty  operation. 

CHAPTER  VI 

OPERATIONS  IN  SUPPURATIVE   CONDITIONS   OF  THE   FOOT  AND  ANKLE 

194.  Suppurative  joint  conditions  about  the  ankle. 

195.  Disease  of  the  oscalcis  and  tarsal  bones. 

196.  Operation  on  the  metatarsus  and  phalangeal  bones  and  joints. 

197.  Operation  in  tuberculosis. 

198.  Osteomyelitis. 

199.  The  Carrell-Dakin  method. 

200.  Plastic  operation  for  open  wounds  following  osteomyelitis. 

201.  Methods  and  principles  of  drainage  in  acute  non-tubercular  suppurative 

joint  disease. 

PART  IV— SHOULDER 
CHAPTER  I 

OPERATIONS  FOR  DISLOCATIONS  AND  DEFORMITIES 

202.  Manipulation  of  the  shoulder  joint  to  relieve  contractures. 

203.  Operation  to  correct  permanent  inward  rotation  of  the  upper  arm. 

204.  Osteotomy  of  the  humerus  to  correct  inward  rotation  of  the  shoulder. 

205.  Osteotomy  for  depressed  acromium. 

206.  Muscle  shortening.    Operation  for  shortening  the  infra  spinatus  to  correct 

inward  rotation  of  the  shoulder. 


xvi  CONTENTS 

207.  Muscle  lengthening  to  correct  partial  or  total  permanent  inward  rotation 

of  the  shoulder. 
20S.  Operation  to  correct  inward  rotation  of  the  arm  in  obstetrical  paralysis. 
Myotomy  of  the  subscapulares  and  of  the  pectoralis  muscles.    Severe 
operation. 

209.  Operation  to  correct  inward  rotation  of  the  arm  in  spastic  paralysis. 

210.  Dislocation  of  the  clavicle. 

211.  Partial  dislocation  of  the  shoulder  due  to  paralysis,  and  in  an  obstetrical 

paralysis  with  or  without  depression  of  the  acromion. 

212.  Partial  dislocation  of  the  shoulder  in  paralytic  conditions. 

213.  Open  operation  in  cases  of  irreducible  dislocation  of  the  shoulder. 

214.  Capsulorrahphy  for  dislocation  of  the  shoulder. 

215.  Operation  for  recurrent  dislocation  of  the  shoulder. 

216.  Operation  for  congenital  high  position  of  the  scapula  or  Sprengel's  de- 

formity. 

217.  Application  of  plaster  of  Paris  bandage  for  the  shoulder. 

CHAPTER  II 

MUSCLE  AND  TENDON  OPERATIONS.      MUSCLE  AND  TENDON  TRANSPLANTATION 

218.  Operation  for  paralysis  of  the  triceps,  transplantation  of  the  deltoid. 

219.  Operation  for  paralysis  of  the  deltoid.    Transplantation  of  the  trapezius. 

220.  Operation  for  paralysis  of  the  deltoid.    Transplantation  of  the  trapezius 

to  part  of  the  pectoralis  major  insertion. 

221.  Operation  for  paralysis  of  the  deltoid.    Pectoralis  major  transplantation. 

222.  Operation  for  paralysis  of  the  biceps,  transplantation  of  the  triceps. 

CHAPTER  III 

OPERATIONS   IN   PARTIAL   AND   TOTAL   PARALYSIS   ABOUT   THE   JOINT 

223.  Flail  condition  of  the  shoulder  with  partial  or  total  dislocations  of  the 

shoulder  due  to  paralysis. 

224.  Osteotomy  for  depressed  acromion  and  capsulorrahphy. 

225.  Arthrodesis  of  the  shoulder  in  paralytic  conditions. 

226.  Bartow  silk  ligament  at  the  shoulder  in  paralytic  conditions. 

CHAPTER  IV 

INCISION,   PUNCTURE   AND   ARTHROTOMY 

227.  Arthrotomy. 

228.  Anterior  incision. 

229.  Posterior  incision. 

230.  Kocher  incision. 

231.  Codman  incision. 

232.  Fracture  of  the  shoulder. 

233.  Fracture  about  the  shoulder. 

234.  Arthrotomy  for  fractures  about  the  shoulder  joint. 

235.  A  traction  apparatus  for  fractures  of  the  shoulder  and  the  shaft  of  the 

humerus. 

236.  A  method  of  treating  overlapping  fractures. 


CONTENTS  xvii 

237.  Fractures  of  long  standing  still  ununited  or  united  with  deformity  prevent- 

ing function. 

238.  Tapping  the  shoulder  joint. 


CHAPTER  V 

OPERATIVE   TREATMENT   IN    CASES   OF   JOINT   ANKYLOSIS 

239.  Partial  excision  of  the  shoulder  for  ankylosis. 

240.  Excision  of  the  shoulder  to  relieve  ankylosis. 

241.  Arthroplasty  for  ankylosis  of  the  shoulder. 

CHAPTER  VI 

OPERATION   IN   SUPPURATIVE    CONDITIONS 

242.  Osteomyelitis. 

243.  Suppurative  conditions  of  the  shoulder. 

244.  Excision  of  the  shoulder  in  suppurative  conditions. 

245.  Excision  of  the  scapula  in  suppurative  conditions. 

246.  Methods  and  principles  of  drainage  in  acute  non-tubercular  suppurative 

joint  disease.    Shoulder. 

PART  V— ELBOW 
CHAPTER  I 

OPERATION   FOR   DEFORMITIES   AND   DISLOCATION   OF   THE   ELBOW 

247.  Dislocations  of  the  elbow. 

248.  Manipulation  of  the  elbow. 

249.  Plaster  of  Paris  for  the  elbow. 


CHAPTER  II 

MUSCLE   AND   TENDON   OPERATIONS.      MUSCLE   AND   TENDON  TRANSPLANTATION 

250.  Transplantation  of  the  triceps  for  paralysis  of  the  biceps.    (See  also  chap- 
ter on  the  shoulder  and  on  the  wrist.) 


CHAPTER  III 

OPERATION  IN  CASES  OF  TOTAL  OR  PARTIAL  PARALYSIS  ABOUT  THE  ELBOW 

251.  Flail  condition  of  the  elbow. 

252.  Silk  ligament  at  the  elbow. 

253.  Fascia  transplantation  for  flail  conditions  of  the  elbow. 

254.  Operation  on  the  skin  for  a  flail  elbow. 

255.  Arthrodesis  for  a  flail  elbow. 


xviii  CONTENTS 

CHAPTER  IV 

INCISION,    PUNCTURE,   ARTHROTOMY  AT  THE   ELBOW 

256.  Arthrotomy. 

257.  Posterior  incision. 

25S.  External  lateral  incision. 

259.  Internal  lateral  incision. 

260.  Anterior  incision  for  reaching  the  elbow  joint. 

261.  Operations  for  fractures  at  the  elbow. 

262.  A  traction  apparatus  for  fractures  at  the  elbow. 

263.  A  method  of  treating  overlapping  fractures. 

26-4.  Fractures  of  long  standing  still  ununited  or  united  with  deformity  prevent- 
ing function. 

265.  Irreducible  dislocation  and  in  multiple  fractures  of  the  elbow. 

266.  Overlapping  fractures  of  both  bones  of  the  forearm. 

267.  Fracture  of  the  olecranon. 

268.  Tapping  the  elbow  joint. 

CHAPTER  V 

ANKYLOSIS   OF   THE   ELBOW 

269.  Excision  or  ankylosis  for  the  elbow. 

270.  Synostosis  at  the  elbow. 

271.  Arthroplasty  for  ankylosis  at  the  elbow  (general  principles). 

272.  Arthroplasty  for  ankylosis  of  the  elbow  (technique). 

273.  Overhead  sling  for  the  arm  following  operation. 

CHAPTER  VI 

OPERATION  FOR  SUPPURATIVE   CONDITION 

274.  Suppurative  conditions  about  the  elbow. 

275.  Osteomyelitis. 

276.  Excision  for  suppuration. 

277.  Methods  and  principles  of  drainage  in  acute  non-tubercular  suppurative 

joint  diseases.    Elbow. 


PART  VI— WRIST 
CHAPTER  I 

DEFORMITIES  AT  THE  WRIST 

278.  Operation  for  Madelung's  deformity. 

279.  Club  hand  operation. 

280.  Contracted  wrist  and  finger,  operation. 

281.  Manipulation  of  the  finger  and  wrist  joints. 


CONTENTS  xix 

CHAPTER  II 

MUSCLE  AND  TENDON  OPERATIONS.      MUSCLE  AND  TENDON  TRANSPLANTATION 

282.  Silk  elongation  for  cut  or  short  tendons. 

283.  Operation  to  give  power  to  supinate  the  forearm  in  cases  of  paralysis  of  the 

supinators.     Tubby  operation.     Transplantation  of   the    pronator- 
radii-teres  to  give  power  of  supination. 

284.  Transplantation  in  the  forearm. 

285.  Operation  for  contracted  or  short  extensors  of  the  wrist  and  fingers.    Ten- 

don lengthening. 

286.  Operation  for  contracted  or  short  extensors  of  the  wrist  and  fingers. 

Lengthening    the   muscles    by    a    subperiosteal    operation    on    the 
condyle. 

287.  Operation  for  contracted  flexors  of  the  wrist  and  fingers.    Tendon  length- 

ening. 

288.  Operation  for  contracted  flexors  of  the  wrist  and  fingers  lengthening  the 

muscles  by  a  subperiosteal  operation  on  the  condyle. 

289.  Operation  for  shortening  the  long  flexors  of  the  wrist  and  fingers.    Muscle 

and  tendon  shortening. 

290.  Operation  for  shortening  the  long  extensor  tendons  of  the  wrist  and  fingers. 

Muscle  and  tendons  shortening. 

291.  Operation  for  paralysis  of  the  extensor  longus  pollicis  or  extensor  longus 

digitorum.    Transplantation  of  the  palmaris  longus. 

292.  Other  transplantation  in  the  forearm  for  paralysis  of  the  extensor  longus 

digitorum  or  the  extensor  longus  pollicis. 

293.  Transplantations  in  the  forearm  for  paralysis  of  the  flexor  longus  digitorum 

'  and  flexor  longus  pollicis. 

294.  Operation  for  paralysis  of  the  flexor  longus  pollicis  when  the  flexor  carpi 

radialis  is  spared. 

295.  Operation  for  paralysis  of  the  flexors  of  the  wrist.    Transplantation  of  the 

extensor  carpi  radialis  and  the  flexor  carpi  ulnaris. 

296.  Nerve  supply  in  the  forearm. 


CHAPTER  III 

INCISION,   PUNCTURE  AND  ARTHROTOMT 

297.  Arthrotomy  at  the  wrist. 

298.  Arthrotomy  at  the  wrist.  Ollier's  incisions. 

299.  Posterior  incision. 

300.  Arthrotomy  at  the  wrist.    Anterior  incision. 

301.  Arthrotomy  at  the  wrist.    Radial  incision. 

302.  Arthrotomy  at  the  metacarpal  and  phalangeal  joints. 

303.  Arthrotomy  for  fractures  about  the  joints. 

304.  Fractures  of  long  standing  still  ununited  or  united  with  deformity  pre- 

venting function.    ■ 

305.  Tapping  the  wrist  joint. 


xx  '  CONTENTS 

CHAPTER  IV 

OPERATIVE   TREATMENT   IN   CASES  OF  JOINT  ANKYLOSIS 

306.  Arthroplasty. , 

307.  Arthroplasty  in  ankylosis  of  the  wrist. 
30S.  Arthroplasty  in  ankylosis  of  the  finger. 

CHAPTER  V 

OPERATIONS  IN   SUPPURATIVE   CONDITIONS 

309.  Suppurative  conditions  at  the  wrist. 

310.  Osteomyelitis  near  the  wrist. 

311.  Excision  of  the  wrist. 

312.  Operation  for  bone  disease  in  the  metacarpal  or  phalangeal  bones  or  their 

joints. 

313.  Methods  and  principles  of  drainage  in  acute  non-tubercular  suppurative 

joint  disease. 

PART  VII 
CHAPTER  I 

MISCELLANEOUS  OPERATIONS 

314.  Torticollis  operation. 

315.  Operation  for  tenosynovitis. 

316.  Bone  grafting. 

317.  Operation  on  rachitic  deformities. 

318.  Arthroplasty  temperomaxillary  joint. 

319.  Infantile  paralysis. 

320.  Plastic  operation  on  the  spine  for  Potts  disease. 

321.  Operation  for  obtaining  ankylosis  of  the  spine.    Albee  operation. 

322.  Operation  for  obtaining  ankylosis  of  the  spine.    Hibbs  operation. 

323.  The  Carrell-Dakin  technique  for  the  treatment  of  suppurative  cases,  com- 

pound fractures,  etc. 

CHAPTER  II 

PLASTER   AND   BRACES 

324.  The  application  of  plaster  of  Paris  bandage. 

325.  Lacing  a  plaster  of  Paris. 

326.  Plaster  of  Paris  bandage  for  the  neck  or  the  head,  neck  and  thorax.    Method 

of  applying  "Plaster  Ropes." 

327.  A  plaster  of  Paris  jacket. 

328.  Plaster  of  Paris  cuirass. 

329.  Plaster  cuirass  for  the  hip. 

330.  Plaster  of  Pars  bandage  for  the  hip.     See  also  plaster  cuirass  for  the  hip 

and  also  congenital  dislocation  of  the  hip  plaster. 

331.  Plaster  of  Paris  for  congenital  dislocation  of  the  hip. 


CONTENTS  xxi 

332.  Application  of  a  hip  plaster  of  Paris  after  fasciotomy.    Or  after  osteotomy 

of  the  hip  or  trochanter. 

333.  Retaining  apparatus  after  operation  on  the  hand. 

334.  Plaster  of  Paris  bandage  after  operation  on  the  knee. 

335.  The  application  of  a  plaster  of  Paris  bandage  after  operation  or  manipula- 

tion of  the  knee.    A  simple  method  of  preventing  rotation  of  a  leg 
plaster.    Plaster  holding  the  knee. 

336.  Plaster  of  Paris  bandage  after  operation  on  the  foot. 

337.  Application  of  plaster  for  varus,  or  equino  varus.    Club  foot  plaster. 

338.  Plaster  of  Paris  bandage  for  valgus. 

339.  Plaster  of  Paris  bandage  after  operation  on  the  toes. 

CHAPTER  III 

PREPARATION  FOR  OPERATION 

340.  Preparation  of  the  skin  for  operation. 

341.  Preparation  of  the  skin  of  the  leg  and  foot  for  operation. 

342.  Preparation  of  the  knee  flexed  at  right  angles  for  operation  on  the  semilunar 

cartilage,  etc. 

343.  Preparation  of  the  skin  of  the  arm  for  operation. 

344.  Preparation  of  the  skin  of  the  shoulder  for  operation. 

345.  Preparation  of  the  skin  of  the  elbow  for  operation. 

346.  Preparation  of  the  skin  of  the  hand  and  forearm  for  operation. 

347.  Preparation  of  the  skin  of  the  hip  for  operation. 


TECHNIQUE  OF  OPERATIONS  ON  THE  BONES, 
JOINTS,  MUSCLES  AND  TENDONS 


TECHNIQUE  OF  OPERATIONS 

PART  I— HIP 


CHAPTER  I 

OPERATIONS     FOR     CONGENITAL     DISLOCATIONS     AND     DEFORMITIES 

OF   THE   HIP 

1.  Simple  Manipulation  for  Congenital  Dislocations  of  the  Hip. — 

The  manipulation  of  the  hip  for  congenital  dislocation  of  the  hip  where 
much  force  is  necessary  should  never  be  done  unless  the  patient  has  been 
walking  on  the  leg  at  least  three  weeks.  Where  the  manipulation  is  done 
in  infants,  if  much  force  is  required,  it  is  better  to  wait  until  they  can 
walk  or  creep  satisfactorily.  There  is  very  much  less  chance  of  breaking 
the  bone  when  it  has  been  used  in  weight  bearing  for  three  weeks  or 
more.  For  simple  manipulation,  the  patient  may  be  put  lying  on  his 
face,  the  thigh  over  the  side  of  the  table.  Pressure  is  put  on  the  tro- 
chanter, with  one  hand  the  hip  is  flexed  and  gradually  abducted  with 
simultaneous  pressure  over  the  trochanter,  pressing  the  head  into  the 
acetabulum. 

Second  method 

The  patient  is  placed  on  his  back,  assistants  hold  the  pelvis  by  pressure 
on  the  anterior  spines  and  pubic  symphisis.  The  operator  flexes  the  hip 
and  abducts  gently  while  he  presses  the  trochanter  upward,  rotating  the 
femur  inward  or  outward  as  the  case  requires.  When  the  head  is  in  the 
acetabulum,  the  capsule  and  muscles  should  be  stretched,  forcing  the 
head  well  into  the  socket  until  the  femur  can  be  brought  parallel  to  a  line 
passed  through  the  anterior  spines,  and  slightly  beyond  so  that  the  knee 
will  be  above  and  posterior  to  it. 

When  a  dislocation  of  the  hip  is  present,  and  the  hip  has  been  out  for  a 
long  time  and  locomotion  has  been  possible,  the  hip  is  often  very  difficult 
to  replace.  At  times  it  will  be  necessary  to  do  a  fasciotomy  at  the  hip 
(see  section  9)  to  relieve  the  hip  flexion  and  then  reduce  the  hip. 
In  difficult  cases  the  Bradford  congenital  hip  machine  (see  figures 
1  to  3)  will  make  the  reduction  possible  or  more  simple.  Whenever  the 
surgeon. has  a  difficult  case  to  reduce  he  should  have  this  machine  at 
hand.  This  apparatus  is  not  effective  in  these  cases  because  of  traction, 
but  in  its  varied  methods  of  using  leverage  for  reduction  and  after  reduc- 

1 


TECHNIQUE  OF  OPERATIONS 


tion  to  assure  a  complete  stretching  of  the  capsule  and  other  contracted 
tissues.  Difficult  cases  that  cannot  ordinarily  be  relieved  may  be  re- 
duced by  this  machine.  Failing  to  reduce  the  hip  by  ordinary  methods, 
the  Bradford  congenital  hip  machine  is  employed  (see  figures  1  to  3). 

2.  The  use  of  Dr.  Bradford's  Congenital  Hip  Machine. — The  patient 
is  etherized  and  placed  on  his  back  on  Dr.  Bradford's  congenital  hip 

machine.  The  sacrum  rests  on 
the  flat  portion  of  the  apparatus 
with  the  tuberosities  of  the  ischii 
resting  firmly  against  the  up- 
rights. The  pelvis  is  fixed  by 
oval  metal  levers  pressing  on  the 
anterior  superior  spines  and 
pubic  bone.  The  screws  are 
tightened  which  hold  these  levers 
in  place,  firmly  fixing  the  pelvis. 
While  the  patient  is  being  placed 
in  position,  a  legging  is  attached 

Fig.    1.    Dr.   Bradford's  congenital  hip  ma-  ,    ,1        r      ,  t         11/ 

chine.  A,  Plate  to  be  thumb  screwed  to  a  table,  around  the  foot  and  ankle  (pee 

B,  Lever  rod  in  position;  used  to  press  on  the  figures  ep   fig.  1).     The  traction 

trochanter  and  force  it  upward  C,  Lever  rod.  rod  (gee  figUres  dm  fig.  1),  is 
D,  Traction  rod.     E,  Traction  legging,  one  for  v  f  .  j 

each  leg.    F,  Perineum  rods.     H,  rods  to  hold  next  placed  in  position  and  ex- 

iiium.    J,  Screw  clamp  to  fasten  to  table,  tension  applied   (see  figure  3). 

L"^^^":^^  The  hip  is  stretched  in  adduc- 

legging.  N,  S-hook  to  close  the  chain.  P,  Rings  tion    and    hyperextension    and 

in  legging  through  which  chain  passes.  S,  The  then  in  hyperextension  and  ab- 

holes  to  receive  traction  rods.  j      ,  •  t~v      •        j.i_    i_  j. 

duction.  During  the  hyperexten- 
sion and  adduction,  the  surgeon  rotates  in  and  rotates  out  while 
the  traction  is  in  force.  The  joint  is  gently  stretched  and 
laxed,  the  operator  applying  force  in  a 
gradually  increasing  manner  until  con- 
siderable force  is  used  and  finally  re- 
laxed entirely.  In  this  manner  a 
rhythmic  application  of  force  is  kept 
up.  No  rough  or  forcible  extension 
without    a    gradually    increasing    or 

gradually  decreasing  force  should   be       Fig.    2.     Patient    on   Bradford    Con- 

emnloved  Bv  this  method  a  mini-  genital  Hip  machine-  Dr-  Bradford's 
empioyea.    r»y  mis  mewioa   a  mini    congenital  hip  machine   (Front  view). 

mum    amount    of    trauma    is    caused.  F.  Perineum  rods.    H,  Rods  to  hold  ilium. 

A  joint  that  at  first  will  seem  almost  S-    Holes   for   traction   rods.     J,   Screw 
.,  ,       ,  .n       j..  .        clamp  to  fasten  to  table. 

impossible  to  move  will  often  give 

way  and  stretch  down.  Where  the  muscles  are  hard  and  firm  it 
is  an  advantage  not  to  overstretch  as  they  all  are  useful  in  main- 
taining the  hip  in  the  acetabulum.  When  the  lever  (see  figure  c, 
fig.  1),  is  placed  under  the  trochanter  with  the  leg  extended,  the  leg  is 
gently  abducted  and  the  surgeon  uses  the  lever  to  lift  the  head  into  place 


re- 


OPERATIONS  FOR  CONGENITAL  DISLOCATIONS  3 

during  the  application  of  traction.  Sometimes  this  is  sufficient  for  re- 
duction. As  soon  as  the  head  is  lifted  over  the  rim  of  the  acetabulum, 
the  traction  is  removed.  The  operator  flexes  the  hip  in  slight  adduction, 
places  the  lever  snugly  under  the  trochanter,  abducts  and  gently  rotates 
in  and  out.  As  the  head  slides  over  the  edge  of  the  acetabulum  more 
abduction  is  made,  increasing  the  force  as  the  operator  assures  him- 
self that  the  head  is  over  the  rim.  Stretching  should  be  continued 
until  the  capsule  has  been  thoroughly  pulled  out  and  the  head  comes 
forward,  filling  the  space  under  the  artery.  When  the  lever  is  in  posi- 
tion holding  the  trochanter  well  forward  the  femur  should  be  flexed 
and  abducted,  the  line  of  the  femur  forced  back  so  that  the  knee  will  be 
posterior  to  a  line  drawn  through  the  anterior  spines,  and  abducted  above 
it  (see  figure  4). 

When  dealing  with  marked  anterior  position  of  the  neck  it  is  often 
necessary  to  use  the  lever,  not  under  the  trochanter,  but  above  it,  press- 
ing the  head  downward,  traction  being  applied  at  the  same  time  that  the 
lever  is  being  used. 

During  the  application  of  plaster  the  position  should  be  maintained 
by  a  skilled  assistant  in  order  that  a  dislocation  at  this  time  will  be  im- 


Fig.  3.  Traction  applied.  H,  Rods  to  hold 
ilium.  F,  Perineum  rods.  S,  Hole  for  traction 
rod.  D,  Traction  rod.  E,  Traction  legging. 
The  leg  may  be  abducted  hyperextended  flexed 
or  adducted  and  traction  applied  in  the  same 
way. 


possible.  The  plaster  should  include 
the  pelvis,  re-enforced  in  front  and 
behind,  holding  firmly  the  tuberosity 
of  the  ischium  and  the  great  tro- 
chanter of  the  leg  operated  on.  It 
should  fit  the  thigh  and  leg  and  foot 
(see  figures  12  to  14).  The  plaster 
is  bivalved,  which  will  allow  the  front  to  be  removed  easily  for  inspection 
of  the  leg.  The  patient  is  placed  on  a  Bradford  frame  (see  figures  8  to  11) , 
which  makes  it  easy  to  move  and  carry  him.  The  Bradford  frame  is 
elevated  from  the  bed  if  the  patient  is  put  up  in  the  Mueller  position. 
Whether  the  Lorenz  or  modified  frog  position  is  used  or  the  Mueller  de- 
pends on  the  operator  who  will  select  the  more  stable  position  for  the  indi- 
vidual case.  If  possible  the  Mueller  position  should  be  adopted.  With  it 
inward  rotation  of  the  hip  as  seen  in  figures  13, 14  is  obtained  at  the  time 
of  the  operation,  while  with  the  Lorenz  position,  the  hip  is  outwardly  ro- 
tated and  must  be  inwardly  rotated  during  the  convalescence.    Dr.  Brad- 


Fig.  4.  A,  A  line  connecting  the  an- 
terior spines  looking  at  the  patient  from 
above.  B,  The  abducted  position  of  the 
femur  with  reference  to  the  line  A.  C, 
A  line  connecting  the  anterior  spines 
viewed  from  in  front  of  the  perineum. 
D,  The  line  of  the  femur  below  the 
horizontal  when  the  knee  is  depressed. 


TECHNIQUE  OF  OPERATIONS 


Fie  5.  Plaster  of  Paris  bandage  ap- 
plied for  double  congenital  dislocation  of 
the  hip,  Lorenz  position.  A,  Shows  the 
plaster  re-enforcement  in  front  over  the 
pubic  bone,  the  re-enforcement  is  flat- 
tened in  a  plane  at  right  angles  to  that 
at  AA  (see  figure  6) . 


ford's  machine- for  the  reduction  of  congenital  hip  has  made  it  possible 
to  reduce  so  many  hips  which  otherwise  would  have  to  remain  out  that 

it  has  been  found  necessary  to  develop 
an  after  treatment  especially  adapted 
to  difficult  cases;  difficult  because 
they  could  not  be  reduced  or  difficult 
because  they  would  not  remain  re- 
duced. 

3.  Post  Operative  Treatment. — 
The  plaster  is  left  in  position  for  two 
months.  At  the  end  of  one  or  two 
weeks  an  x-ray  is  taken  to  see  the 
exact  position  of  the  hip.  The  front 
half  of  the  plaster  is  removed  for 
this  purpose  on  the  x-ray  table. 
The  patient  remains  on  the  Brad- 
ford frame.  The  front  of  the  plaster  is  replaced  and  the  patient  put 
back  to  bed.  After  eight  or  ten  weeks  the  plaster  is  cut  away  below 
the  knee,,  allowing  the  pa- 
tient to  move  the  knee  and 
ankle.  At  the  end  of  the 
twelfth  week,  the  front  of 
the  plaster  is  removed  for  a 
short  time  twice  a  day  and 
the  patient  encouraged  to 
kick  the  leg  and  lift  the 
knee.  The  time  is  extended  as  the  patient  improves,  until  the  patient 
is  kicking  the  leg  for  about  six  or  eight  hours  a  day.    As  the  muscles  are 

seen  to  be  strong,  the  patient  is  allowed  to 
creep  on  the  floor  for  twenty  minutes  twice 
a  day  with  the  front  and  back  of  the  plaster 
firmly  fastened.  This  time  is  gradually 
increased  until  the  patient  creeps  six  or 
eight  hours  a  day.  When  the  patient  has 
been  crawling  with  the  plaster  on  for  four 
hours  a  day  and  can  do  so  fairly  vig- 
orously, in  renewing  the  plaster  the  leg  is 
allowed  to  adduct  as  much  as  it  will.  When 
the  muscles  are  not  strong  any  renewal  of 
the  plaster  should  maintain  the  original  abducted  position. 

At  the  end  of  the  fifth  or  seventh 
month  the  patient  is  allowed  to 
creep  without  the  plaster.  The  plas- 
ter is  always  re-applied  at  night  until 

,,  ..      .    .  i,        A,     ,i  i      c       Fig.   8.     Posterior    view    of    Bradford 

the  patient  is  well.    At  the  end  of  frame  showing  lacing  of  cioth  on  frame 

the     ninth     Or     tenth     month,     the    and  opening  for  use  of  bed  pan. 


Fig.  6.  Shows  the  bridge  like  appearance  of  the 
plaster  re-enforcement  over  the  pubic  bone  as  viewed 
from  the  front. 


Fig.  7.  Posterior  view  in  Muel 
ler  position.  A,  Plaster  re-enforce 
ment  over  the  sacrum. 


?<-?<.  S 


3f 


OPERATIONS   FOR  CONGENITAL  DISLOCATIONS 


Fig.  9.     Bradford  frame.    Showing  method  of  elevating  the 
frame  by  iron  hooks  to  the  head  and  foot  of  the  bed. 


Fig.  10. 


Bradford  frame  elevated  on 
boxes. 


patient  is  allowed 
to  stand  and  walk 
for  the  first  time. 
Then  the  hips  will 
be  found  to  be 
strong,  evenly  de- 
veloped and  resistant  to  dislocation  by  any  slight  falls.  The  patient 
should  be  seen  once  a  month  for  the  following  six  months.    After  that 

once  in  three  or  four  months  until 
locomotion  is  perfect. 

With  this  form  of  after  treatment 
the  hips  are  not  likely  to  dislocate. 
The  muscles  are  firm  and  strong 
and  the  patient  healthy.  It  has 
been  found  more  advantageous 
than  that  form  of  after  treatment 
which  allows  the  patient  to  walk  and  bring  the  legs  down  by  successive 
plasters.  There  is  no  danger  of  stiffness  for  motion  is  started  early. 
There  is  almost  no  danger  of  disloca- 
tion as  the  muscles  are  made  strong 
from  the  start  and  they  all  tend  to  hold 
the  head  in  the  acetabulum. 

In  very  strong  patients,  the  abduc- 
tors and  tissues  on  the  outer  side  and 
above  the  femur  will  resist  the  adduc- 
tion   and    make    walking    awkward, 

sometimes   for   two    Or  three  months.        Fig.  ll.     Lorenz  position  in  plaster 

Gentle  stretching  and  massage  are  of  viewed  from  above  the  bed,  the  feet 

j  .  .    ,1  •      ,  •  rro.  arid  sacrum  touch  the  bed. 

advantage  at  this  time.     There  is  no 

disadvantage  in  'this  provided  there  is  good  motion  at  the  hip.    These 

cases  are  less  apt  to  dislocate  than  the  ones  which  adduct  readily.    The 

^!^______^         cases  that  adduct   readily  are  the  ones 

•n~^--2=====r,  J  C/^F  wn^cn  s^ould  be  watched  carefully.     In 

*~~- ^>"""     both  types  of  cases  the  walking  becomes 

Jttis&szStoSx.  norr,1  sradua"y- There  is  often  a  ro11 

The  plaster  is  split  so  that  the  front  or  slight  limp  when  the  patient  is  tired, 
half  may  be  removed  and  replaced.  The  original  position  in  plaster  is  main- 
tained until  the  muscles  are  strong  and  the 
patient  is  crawling  at  least  four  hours  a  day 
with  the  plaster  on.  When  the  patient  can 
crawl  vigorously,  in  renewing  the  plaster  the 
leg  is  allowed  to  adduct  as  much  as  it  will  and  a 
fresh  plaster  is  applied  with  the  leg  adducted. 
If  the  leg  will  adduct  completely  it  should 

be  put  up  in  an  abducted  position  of  fifteen  ^ste rT^ee^+  iT™j}°Zt  *t! 
degrees.    If  the  muscles  are  not  strong  in  abducted. 


Mueller  position  in 


TECHNIQUE  OF  OPERATIONS 


reapplying  the  plaster  the  original  position  of  abduction  to  ninety  de- 
grees should  be  maintained.    After  six  months,  in  renewing  the  plaster 

the  leg  may  be  allowed  to  come  down 
straight  if  it  will. 

The  above  method  of  after  treat- 
ment has  been  used  about  eight  years. 
It  was  developed  at  first  by  the  writer 
for  those  cases  that  it  was  not  pos- 
sible to  successfully  reduce  without 
a  machine  for  reduction,  either  be- 
cause they  redislocated  and  showed 
no  permanency  of  result  or  because 
they  were  too  difficult  to  replace  by  hand  or  by  hand  assisted  by 
a  traction   apparatus.    In  many,  the  detail  of  the  after  treatment 


Fig.  14.  Mueller  position  in  plaster 
viewed  from  the  foot  of  the  bed.  The 
plaster  is  split  so  that  the  front  may  be 
removed  and  replaced. 


Fig.  15.     Manipulation  of  the  hip  in  the  prone  position. 

as  described  was  the  important  factor  in  obtaining  a  permanent  result. 
This  treatment  was  adopted  at  first  only  for  the  difficult  cases;  now  it 

is  used  by  us  for  all  cases. 

Among  the  early  cases,  three 
were  put  through  this  method 
of  after  treatment.  The  course 
was  shortened  to  three  months. 
They  were  all  running  about 
on  their  legs  in  that  time.  One 
dislocated.  Time  enough  had 
not  been  allowed  for  shorten- 
ing of  the  capsule  and  growth  of  the  bone.  For  this  reason  the  time 
was  extended  to  nine  or  ten  months  before  allowing  the  patient  to 
stand.  The  legs  are  stronger, 
less  apt  to  dislocate  and  there 
is  no  stiffness. 

In  the  poliomyelitis  case  or 
paralytic  dislocation  the  mus- 
cles are  usually  weak  or  en- 
tirely    paralyzed,     making    it  j. 
necessary  m   the  majority  of  and  hyperextension. 


Fig.  16.     Manipulation  of  the  hip.    Rotation 
out  and  hyperextension. 


OPERATIONS  FOR  CONGENITAL  DISLOCATIONS  7 

cases  either  to  do  an  open  operation  and  fasten  the  hip  in  the  joint 
after  reduction  as  above  described  or  to  do  an  arthrodesis  at  the  hip  in 
order  to  make  it  useful  for  weight  bearing. 

When  there  is  a  great  deal  of  twist  in  the  neck  of  the  femur,  an  os- 
teotomy of  the  neck  or  of  the  femur  will  relieve  the  twist.  From 
experience  it  has  been  found  that  it  is  rarely  necessary  in  younger 
cases  to  perform  an  osteotomy  in  thoroughly  reduced  heads  where 
the  after  treatment  is  thorough.  The  torsion  in  time  disappears. 
The  twist  in  the  neck  forward  will  not  interfere  with  the  reduction  but 
when  it  is  present  the  surgeon  should  force  the  head  well  into  the  ace- 
tabulum and  stretch  the  capsule  completely  so  that  it  fits  well  around 
the  head. 

4.  Open  Operation  for  Dislocation  of  the  Hip. — The  open  method 
for  treatment  of  dislocation  of  the  hip  is  adopted  for  the  hip  which 
otherwise  could  not  be  reduced  or  for  the  hip  which  will  not  remain 
reduced.  After  following  the  above  method  of  treatment,  when  it  is 
impossible  to  reduce  a  dislocation  of  the  hip  or  when  it  will  not  remain 
in  the  socket  after  careful  reduction  and  after  treatment,  an  operation 
by  incision  becomes  indicated. 

OPERATION 

Before  preparing  the  skin  for  operation,  the  Bradford  congenital  hip 
machine  is  used  and  the  hip  reduced  as  described  above. 

After  cleansing  and  sterilizing  the  skin,  sterile  sheets  should  be  placed 
around  the  leg  in  such  a  way  that  it  may  be  manipulated  in  any  position 
by  an  assistant. 

The  operator  stands  outside  of  the  leg  to  be  operated  on.  An  incision 
is  made  from  the  anterior  superior  spine  to  the  upper  edge  of  the  great 
trochanter  and  then  down  along  its  anterior  border.  Other  incisions 
may  be  preferred  (see  Arthrotomy  at  the  Hip).  The  fascia  lata  and 
tensor  fasciae  femoris  is  retracted  and  the  gluteus  minimus  removed  from 
its  insertion  on  the  great  trochanter  and  retracted  upward  and  back- 
ward. The  leg  is  forcibly  abducted  and  outwardly  rotated.  The  capsule 
is  incised  from  above  downward  and  from  within  outward,  parallel  to 
its  fibers.  The  incision  is  carried  down  from  the  anterior  inferior  spine 
to  the  intra  trochanteric  line.  The  hip  is  reduced  by  flexing  in  adduc- 
tion, then  outward  rotation  or  inward  rotation  in  abduction.  A  sterilized 
lever  is  placed  under  the  trochanter  and  all  resisting  tissues  are  separated 
while  the  head  is  forced  into  place.  If  necessary  the  head  is  brought  out 
into  the  wound  and  the  acetabulum  and  head  inspected.  Any  con- 
strictions of  the  capsule  are  cut,  dividing  them  in  a  line  with  their  fibers. 

After  placing  the  head  in  the  acetabulum,  the  capsule  is  shortened  by 
mattress  sutures  made  with  heavy  silk  number  fourteen  or  number 
sixteen  or  eighteen.  The  deep  tissues  are  brought  together  with  inter- 
rupted chromic  catgut  sutures  number  00,  the  superficial  tissues  with 
interrupted  chromic  catgut  sutures  number  00,  the  skin  with  continuous 


8  TECHNIQUE  OF  OPERATIONS 

chromic  catgut  sutures  number  00.  The  hip  is  held  in  position  by  means 
of  a  plaster  of  Paris  bandage  in  either  a  Mueller  or  Lorenz  position  (see 
figures  11  to  14),  as  described  above.  The  after  treatment  varies  in 
no  way  from  that  for  congenital  hip  dislocation  as  described  above. 

5.  Plaster  of  Paris  for  Congenital  Dislocation  of  the  Hip. — Follow- 
ing the  operation  for  congenital  dislocation  of  the  hip  a  plaster  of  Paris 
bandage  is  applied  as  follows:  stockinet  or  other  suitable  covering  is 
applied  to  the  pelvis  and  legs.  Felt  pads  are  applied  over  the  anterior 
spines,  over  the  top  of  the  trochanter,  under  the  sacrum  and  over  the 
internal  condyles  of  the  femur.  A  well  fitting  plaster  is  then  applied 
over  the  thighs  and  pelvis  for  a  double  case;  or  in  a  simple  case  over  one 
thigh,  with  a  few  turns  over  the  other,  to  prevent  the  pelvic  portion 
from  slipping  up.  Heavy  plaster  re-enforcement  or  plaster  ropes  are 
placed  in  front  over  the  pelvic  bone  (see  figures  5,  6,  7),  along  each  thigh 
in  front  to  prevent  the  breaking  near  the  anterior  spine.  A  similar  re- 
enforcement  is  placed  behind  it  on  the  sacrum  and  down  the  back  of 
the  thigh  (see  figures  6,  7).  More  plaster  bandages  are  used  to  bind  this 
re-enforcement  to  the  rest  of  the  plaster.  The  thigh  of  the  dislocated 
hip  or  hips  should  be  parallel  to  a  line  connecting  the  anterior  superior 
spines  and  if  possible  the  knees  should  be  above  this  line  and  posterior 
to  it.     This  will  show  good  over-correction. 

The  plaster  should  pull  the  trochanter  down  and  hold  it  firmly.  The 
tuberosity  of  the  ischium  should  be  held  firmly  and  be  well  padded  when 
the  part  of  the  plaster,  including  the  pelvis  and  thigh  and  knee  is  harden- 
ing. Padding  is  applied  to  the  lower  leg  and  foot  and  the  plaster  con- 
tinued downward,  the  foot  is  held  at  right  angles. 

It  is  important  to  maintain  the  desired  position  of  the  thigh  and  have 
the  plaster  harden  immediately  maintaining  the  Mueller  or  Lorenz  posi- 
tion while  completing  the  plaster  down  to  the  foot.  The  plaster  should 
be  split  into  an  anterior  and  posterior  half  as  shown  in  figures  12,  14, 
and  laced  as  shown  in  figures  460  to  464. 


CHAPTER  IJ. 

! 
muscle  transplantations:  muscle  and  tendon  operations  about 

THE   HIP 

6.  Operation  for  Manipulation  of  the  Hip.  Hip  Flexion  Due  to 
Contracted  Soft  Tissues. — Hip  contracture  due  to  a  short  tensor 
fasciae  femoris  may  be  relieved  when  very  slight  by  multiple  subcuta- 
neous tenotomies  of  the  fascia  lata  and  sometimes  by  manipulation. 

Under  ansesthesia  the  patient  lying  on  his  abdomen  on  a  low  table  or 
couch  (see  figure  15),  the  operator  holds  the  leg  at  the  knee,  another 
assistant  presses  with  both  hands  over  the  buttock.  The  operator 
adducts  (figure  16)  the  leg  and  hyperextencls.  He  combines  the  hyper- 
extension  (figures  16,  17,)  with  inward  rotation  and  with  outward 
rotation  alternately.  The  patient  lying  on  his  abdomen,  the  stretching 
may  be  varied  by  elevating  the  knee  on  hard  pillows  until  the  pelvis 
is  well  off  of  the  table,  the  assistant  pressing  down  on  the  buttock  will 
stretch  the  resistant  tissues  at  the  hip.  The  patient  lying  on  his  back 
flexion  abduction  and  rotation  and  a  combination  of  these  motions  are 
used  to  limber  the  hip.  Most  of  these  cases  of  hip  flexion  even  when 
they  seem  slight  are  difficult  to  correct,  for  it  is  almost  impossible  to 
prevent  the  tilting  of  the  pelvis  and  curving  of  the  lumbo  sacral  spine. 
For  this  reason  the  operator  should  be  ready  to  do  a  fasciotomy  when  a 
simple  manipulation  has  failed.  If  the  patient  is  not  very  strong  the 
fasciotomy  should  be  resorted  to  at  once  as  it  is  much  shorter  than  a 
difficult  manipulation  at  the  hip.  There  is  less  damage  and  trauma  and 
no  shock  when  done  quickly,  see  Fasciotomy,  described  elsewhere. 

7.  Manipulation  of  the  Hip  under  an  Anaesthetic  for  Flexion,  Adduc- 
tion and  Abduction  Deformities. — If  there  is  bony  ankylosis  it  is 
useless  to  attempt  manipulation;  if  the  limitation  of  motion  is  in  the 
capsule  and  the  other  soft  parts,  the  result  of  manipulation  is  often  very 
satisfactory.  If  the  limitation  of  motion  is  considerable  and  of  long 
standing,  the  muscles  will  often  need  to  be  lengthened  as  described  in 
these  pages  under  tendon  or  muscle  lengthening,  tenotomy,  fasciotomy, 
etc.  In  addition  to  the  muscle  lengthening  the  joint  capsule  will  need 
stretching;  this  can  be  done  by  manipulation.     See  also  sections  36,  37. 

Manipulation  of  the  joint  is  contra  indicated  if  there  has  been  tubercu- 
losis of  the  joint  or  recent  disease.  Manipulation  is  very  apt  to  stir  up 
the  disease  and  in  tuberculosis  may  even  cause  meningitis.  When  there 
has  been  no  disease  present  for  at  least  a  year,  it  is  safe  to  manipulate 
carefully.  At  the  hip  no  great  amount  of  force  should  be  used  if  the 
limb  has  not  been  weight  bearing  for  some  time.    The  bone  that  has  not 

9 


10  TECHNIQUE  OF  OPERATIONS 

borne  weight  is  brittle  and  will  easily  fracture.  If,  in  the  x-ray,  the 
head  and  neck  and  shaft  show  good  heavy  bone  and  weight  bearing  has 
been  constant  the  danger  of  fracture  will  be  diminished. 

Under  anaesthesia  the  patient  lying  on  his  back,  the  operator  adducts 
the  hip  as  far  as  it  will  go,  he  then  gently  stretches  and  relaxes  as  it 
adducts  further.  This  may  be  combined  with  inward  rotation  and  then 
with  outward  rotation.  After  working  in  this  manner  to  increase  the 
adduction,  he  abducts  the  hip  as  far  as  it  will  go  and  then  gently  stretches 
and  relaxes  as  he  abducts  further.  This  should  be  combined  with  rotation 
in  and  rotation  out.  The  pelvis  should  be  fixed  by  apparatus,  a  traction 
apparatus  with  a  pull  on  both  legs  is  a  very  satisfactory  method  of 
holding  the  pelvis.  Assistants  may  hold  the  pelvis  with  their  hands 
flexing  the  other  thigh  as  far  as  it  will  go.  Roughness  should  be 
avoided  as  it  will  cause  unnecessary  trauma  and  will  give  unnecessary 
pain  and  swelling  after  operation. 

The  hip  is  next  flexed  forty-five  degrees  and  rotated  in  and  out  as 
far  as  it  will  go  and  then  stretched  gently  in  inward  and  in  outward 
rotation.  This  is  repeated  with  the  patient  lying  on  his  abdomen.  The 
rotation  should  not  be  forced  beyond  thirty-five  degrees.  The  adduction 
to  thirty  degrees,  the  abduction  to  forty-five  degrees.  The  flexion 
to  about  ninety  degrees  and  if  it  is  difficult,  even  less.  Abduction,  flexion 
and  hyperextension  of  twenty  degrees,  free  and  easy,  are  the  motions 
that  are  the  most  useful.  The  operator  should  not  attempt  too  much; 
if  the  hip  will  yield  this  much  in  difficult  cases  it  is  often  possible  to  get 
other  motions  and  more  of  these  by  gentle  exercise  in  the  after  treat- 
ment provided  the  motion  obtained  is  free  and  easy. 

To  obtain  a  great  radius  of  motion  under  anaesthesia  and  cause  a  great 
deal  of  trauma  will  net  very  little  motion  as  an  end  result.  The  operator 
should  content  himself  with  the  important  motions  and  obtain  these 
and  the  others  as  far  as  he  can  by  gentle  stretching  and  relaxing. 
It  is  surprising  the  amount  that  can  be  obtained  by  persistent  stretch- 
ing in  the  different  directions  rather  than  by  the  use  of  overbearing 
force. 

While  the  patient  lies  on  his  abdomen,  the  hip  is  manipulated  to  in- 
crease the  hyperextension  by  flexing  the  knee  and  by  hyperextending 
the  hip  in  adduction  as  well  by  hyperextending  it  in  abduction.  These 
motions  are  combined  alternately  with  inward  and  with  outward  rota- 
tion. Traction  is  applied  in  bed  following  the  manipulation.  As  the 
signs  of  local  reaction  subside  the  traction  is  gradually  omitted  and  the 
patient  gotten  up  walking  on  the  other  leg  and  swinging  the  manipulated 
leg ;  exercise  in  bed  should  be  done  six  or  eight  times  a  clay.  As  the  leg 
acquires  strength  weight  bearing  is  begun  four  to  six  steps,  six  or  eight 
times  a  day  and  increased  not  too  rapidly  but  as  the  local  strength 
and  reaction  allows.  If  the  patient  has  a  little  motion  in  all  direc- 
tions these  may  be  materially  increased,  especially  in  patients  under 
forty. 


MUSCLE  TRANSPLANTATIONS 


11 


8.  Fasciotomy  at  the  Hip.  Transplantation  of  the  Hip  Flexors  at 
the  Ilium.* — The  patient  lies  on  his  back.  The  skin  preparation  is 
made  from  the  middle  line  of  the  abdomen  in  front,  backward  to  the 
middle  line  behind,  and  around  the  whole  leg  to  the  knee.  The  leg  is 
then  enveloped  in  a  sterile  sheet  up  to  the  groin  so  that  it  may  be 
manipulated  during  the  operation.  The  operation  is  not  one  that 
involves  any  shock  to  the  patient.      It  is  indicated  wherever  the  soft 


Fig. 


18.     Fasciotomy;  transplantation  of 
the  hip  flexors,  line  of  incision. 


Fig.  19.  Fasciotomy;  transplantation  of 
the  hip  flexors,  incision  of  the  tensor  fascia 
femoris. 


tissues  are  contracted  causing  the  back  to  arch  when  the  patient 
stands.  Such  cases  are  often  prevented  from  walking  on  account  of 
the  hip  deformity  which  may  be  single  or  double.  Cases  with  com- 
plete paralysis  below  the  hips  can  be  made  to  walk  with  apparatus 
if  the  arms  are  good  enough  to  use  crutches.  With  contracted  hips 
it  is  additionally  difficult  or  impossible.  In  these  cases  it  is  advisable  to 
do  the  fasciotomy  and  allow  the  hips  to  be  fully  extended. 


OPERATION 

An  incision  is  made  parallel  to  the  line  of  the  femur  one  and  one-half 
inches  posterior  to  the  anterior  superior  spine  (see  figure  18)  extending 
two  inches  above  and  two  inches  below  it.  The  subcutaneous  tissues 
are  dissected  up  and  retracted  throughout  the  length  of  the  incision 
exposing  the  tough  fibers  of  the  fascia  lata  extending  from  the  anterior 
superior  spine  to  the  top  of  the  great  trochanter  (see  figure  19).  These 
fibers  are  incised  from  the  anterior  superior  spine  to  the  great  trochanter 
(see  figure  19).  The  dissection  up  to  the  present  has  been  practically 
free  from  any  but  very  superficial  bleeding.  A  few  of  the  superficial 
fibers  of  the  underlying  muscles  are  cut  across.  The  anterior  flap  is- 
next  retracted  exposing  the  anterior  superior  spine  (see  figure  20).  An 
osteotome  is  placed  over  the  anterior  superior  spine  and  splits  the 
periosteum,  peeling  it  away  from  the  crest,  extending  two  inches  back- 
ward to  the  inner  and  outer  side.  The  osteotome  is  used  to  clear  the 
top  of  the  anterior  superior  spine  of  periosteum  which  peels  readily  from 
the  sides  of  the  crest.  The  periosteum  is  removed  downward  to  below 
the  anterior  inferior  spine  (see  figures  21,  22,  23).  There  is  a  little 
oozing  from  the  periosteum  but  no  bleeding  if  the  surgeon  is  careful 
to  keep  the  osteotome  on  the  bone  under  the  periosteum.  When  the 
crest  has  been  cleared  on  both  sides  and  below  the  anterior  superior 

*  Soutter  operation. 


12 


TECHNIQUE  OF  OPERATIONS 


spine,  a  sponge  may  be  used  to  push  all  of  the  soft  tissues  downward 
toward  the  knee.  When  this  has  been  accomplished  the  patient  is 
turned  slightly  on  the  other  side,  a  sterile  towel  folded  twice  is  placed 
over  the  buttock  and  the  hip  hyperextended,  the  finger  of  the  operator  in 
the  wound  pressing  down  the  deep  and  superficial  fibers  which  are  found 
resistant.    Very  often  the  fascia,  which  is  continuous  with  the  abdominal 

fascia,  is  very  much  toughened  and 
resists  the  hyperextension  of  the 
hip.  When  the  hip  has  been  satis- 
factorily hyperextended,  the  su- 
perficial fat  which  has  not  been 

Fig.    20.    Fasciotomy;    transplantation  of    Separated    fl'Om    the    skill    flap,    is 

the  hip  flexors,  subperiosteal  removal  of  the  drawn  over  the  crest  of  the  ilium 

tissues  from  the  anterior  and  inferior  spines,    „    j  „„<    ,  •  •  -ji    ■    .  A     1 

also  from  the  sides  of  the  erest  of  the  ilium.     and  anterior  spine  with  interrupted 

chromic  catgut  number  00.  Only 
the  fat  and  skin  are  sutured.  When  the  operation  is  performed  with 
an  osteotome,  in  the  manner  described  above,  there  is  rarely  any 
bleeding.  It  is  very  important  in  the  after  treatment  that  the  head, 
shoulders  and  buttocks  should  rest  on  a  level,  being  held  in  this 
way  on  a  Bradford  frame  (see  figures  24,  9,  10).  The  legs  are  hy- 
perextended backward  below  the 
frame.  This  position  is  more 
comfortably  maintained  by 
means  of  plaster  of  Paris  ap- 
paratus extending  from  the  nip- 
ple line  tO  the  toes  anteriorly,  hip  flexors,  the  tissues  from  the  anterior  superior 
and  fl'Om  the  tOD  of  the  Sa-  sPme  an<^  below  it  pushed  downward  allowing 
, ,      ,       ,        L     .      .     ,      ,  the  leg  to  be  lowered  without  causing  lordosis. 

crum  to  the  heels  posteriorly  (see 

figures  25  to  27).  A  large  window  should  be  cut  over  the  abdomen 
from  the  ensiform  to  a  little  above  the  pubic  bone.  The  plaster  is 
re-enforced  for  this  purpose  as  shown  by  the  lines  drawn  on  figures  28, 
29.  This  position  is  maintained  eight  weeks.  The  patient  is  then 
gotten  up  gradually  and  encouraged  to  walk  with  a  short  light  plaster 

and  crutches.  Later  braces  if 
necessary  are  applied  and  the 
hyperextended  position  used  for 
two  or  three  hours  a  day  only. 

Fig.  22.     Fasciotomy;  transplantation  of  the    A   plaster  shell   and   a  Bradford 
hip  flexors,  the  crest  of  the  ilium  exposed  lat-    frame  is  USed  during  the  hours 

of  hyperextension;  this  makes 
it  possible  to  obtain  the  correct  position  each  time  (see  figure  24). 
It  is  possible  with  this  operation  to  relieve  right  angle  contractures 
due  to  soft  tissues.  WThen  a  partial  or  fibrinous  ankylosis  of  the  hip 
exists  in  connection  with  right  angle  flexion,  this  operation  for  relieving 
the  soft  tissues  greatly  simplifies  the  hip  operation.  In  cases  that  have 
not  walked  for  a  long  time  on  an  ankylosed  hip,  there  is  great  danger 


MUSCLE  TRANSPLANTATIONS 


13 


of  breaking  the  neck  of  the  femur,  during  manipulation,  the  contracted 
soft  tissues  acting  as  a  bow-string  during  manipulation.  If  on  the 
other  hand  these  are  relieved  by  this  operation,  the 
hip  joint  may  be  manipulated  or  operated  on  more 
freely. 

In  chronic  conditions  whether  paralytic  or  not 
where  the  sitting  or  flexed  hip  position  has  been 
maintained  over  a  long  period  of  time,  the  flexion  is 
difficult  to  overcome  even  by  operative  measures, 
for  while  we  may  hold  the  femur,  it  is  almost  impos- 
V  /  sible  to  hold  the  pelvis  and  spine  from  tilting  forward 

j  during  the  process  of  over  correction.    A  flexed  knee 

may  be 
manip- 
ulated 
easily 
for  it  is 
possible 
to  grip 
the  tibia 


Fig.  23.  Fasciot- 
omy ;  transplantation 
of  the  hip  flexors, 
showing  the  separa- 
tion of  tissues.  An- 
terior view,  notice 
the  separation  of  the 
periosteum  from  the 
bone. 


Fig.  24.  Position  of  the  patient  on  a  Bradford 
frame  after  transplantation  of  the  flexors  at  the  ilium. 
Soutter  operation.  The  hip  operated  on  must  be  hy- 
perextended  and  adducted. 


and  the  femur.  At  the  hip  it  is  another  matter;  the  pelvis  is  difficult  to 
hold.  This  operation  has  been  found  of  great  value  and  the  deformity 
is  not  apt  to  recur,  for  the  length- 
ening of  the  muscles  is  definite 
and  permanent.  They  are  not 
cut  across ;  they  retain  their  func- 
tion, reattaching  themselves  lower 
down. 

9.  Fasciotomy  to  Relieve  Flex- 
ion and  Abduction  of  the  Hip. — 
See  also  sections  36,  37.  When 
there  is  contraction  of  the  hip 
flexors  there  is  usually  a  short 
tensor  fascia  femoris  which  gives 
an  abducted  position  of  the  hip. 
This  is  a  common  deformity  in 
poliomyelitis. 

In  spastic  conditions  and  in  cer- 
tain arthritic  conditions  when  the      FlG-  25.    Posterior 

muscles  shorten  after  long  periods    view  of   a  plaster  to       view  of  a  plaster  to 

of  contraction  due  to  the  disease  hold  both  hips-  hold  both  ^p3- 

or  spasm,  the  adductors  are  more  commonly  shortened  with  the  flexors. 
For  this  reason  in  spastic  paralysis  in  addition  to  doing  a  fasciotomy  or 
transplantation  of  the  upper  attachment  of  the  flexors  of  the  hip,  it  is 
necessary  to  do  a  myotomy  of  the  adductors  or  of  the  inner  hamstrings 
or  both. 


14 


TECHNIQUE  OF  OPERATIONS 


r 


"When  the  position  of  hip  flexion  is  due  to  old  hip  disease  or  arthritis, 
the  adductors  are  usually  short  as  well  as  the  flexors  of  the  hip.  In  this 
type  of  case  there  may  be  hip  ankylosis  either  fibrous  or  bony. 

In  relieving  the  attachment  of  the  flexors  at  the  ilium  and  transplant- 
ing them  downward  as  described  above,  the  adductors  may  be  my'otom- 
ized  or  lengthened  and  the  bone  or  joint  deformity  relieved  at  the  same 
time.  Each  of  these  conditions  is  described  under 
manipulation  of  the  hip;  osteotomy  at  the  hip,  sub- 
trochanteric osteotomy,  myotomy,  muscle  and  tendon 
lengthening  and  fasciotomy  at  the  hip.  See  also  sec- 
tions 36,  37. 

10.  Application  of  a  Hip  Plaster  of  Paris  Bandage 
after  Fasciotomy,  or  after  Osteotomy  at  the  Hip  or 
Trochanter. — It  may  be  as  well  to  go  into  more  de- 
tail as  to  the  application  of 
plaster.  A  loose  ill-fitting 
plaster  does  not  hold  the 
patient  or  the  bone.  The 
sheet  wadding  should  fit  the 
leg  snugly  and  the  body 
perfectly.  After  the  appli- 
cation, the  outlines  of  the 
patient  should  be  distinct 
and  shapely.  A  pad  of 
heavy  felt  is  placed  over 
the  sacrum,  another  one 
over  each  anterior  spine. 
A  thin  layer  of  felt  covers 
the  chest  from  the  posterior 
Fig.  27.  Side  view  axillary  line  laterally  and 
of  a  plaster  to  hold  reaching  down  to  the  lower 

both    hips.       Notice        ,  P  .-.         .,  ml        ,        . 

the  opening  over  the  edge  of  the  ribs.  The  sheet 
abdomen  and  above  wadding  should  be  applied 
lavishly  but  firmly  all  over 
the  patient  but  it  should  fit 
snugly.  A  large  thick  felt 
pad  is  placed  over  the  tu- 
berosity of  the  ischium  and 
the  perineum  of  the  affected  side  (see  figures  lines  where  the  plaster  should 
30,  31).  A  long  rope  of  plaster  is  first  applied  be  re"enforced-  Front  view- 
over  this  felt,  holding  the  felt  against  the  tuberosity  of  the  ischium. 
This  plaster  rope  should  be  long  enough  to  extend  to  the  axilla  in  front 
and  to  the  axilla  behind  (see  figure  32).  Its  ends  are  held  by  a  nurse 
during  the  application  of  the  plaster  around  the  back  of  the  patient  over 
the  ropes  (see  figures  58  to  61) .  This  plaster  rope  should  be  used  after  os- 
teotomy or  fractures  at  the  hip.     It  is  not  necessary  in  simple  correction 


the  pelvis  behind. 
After  transplanta- 
tion of  the  hip  flex- 
ors, this  plaster  is  ap- 
plied with  the  hips 
hyperextended. 


Fig.   28.      Plaster  of  Paris 
for    both    hips,    showing    by 


MUSCLE  TRANSPLANTATIONS 


15 


of  hip  deformity.  The  plaster  is  then  applied  to  the  leg  as  far  as  the  knee, 
the  knee  being  well  padded  with  felt  in  addition  to  the  sheet  wadding. 
The  plaster  should  then  be  reinforced  heavily  in  the  front  of  the  leg  and 
hip,  again  over  the  pubic  bone  and  front  of  the  leg,  again  on  the  front  up 
to  the  nipple.  Additional  reinforcement  should  be  made  on  the  side  of 
the  leg  well  posterior  and  extends  up  the  side  of  the  thorax.  In  a  heavy 
person,  each  of  these  reinforcements  should  be  one  inch  thick  and  two 
inches  wide  (see  figures  28,  29) .    Further  reinforcement  of  the  plaster  is 


Fig.  30.  Method  of  applying  a  plas- 
ter rope  to  the  tuberosity  of  the  ischium. 
(Note  plaster  rope  X  over  felt  padding. 
This  is  used  to  prevent  a  hip  plaster  from 
sliding  upward.    (See  figure  31.) 


Fig.  29.  Side  view 
of  plaster  for  both 
hips,  showing  by 
lines  where  the  plas- 
ter should  be  re-en- 
forced. 


Fig.  31.  Shows 
the  plaster  rope 
turned  back  and 
buried  in  the  plaster. 


Fig.  32.  Showing 
the  plaster  rope  cov- 
ered with  the  rest  of 
the  plaster. 


made  across  the  front  of  the  chest,  the  sides  of  the  abdomen  and  over  the 
pubis  (see  figures  28) .  The  plaster  is  finished  rapidly  down  from  the  axilla 
to  the  knee  on  the  affected  side  and  down  about  six  inches  on  the  opposite 
thigh.  As  soon  "as  the  plaster  has  hardened  the  traction  is  removed 
gently  from  each  leg.  Sheet  wadding  is  applied  around  the  foot  and 
ankle  of  the  affected  side  and  the  plaster  is  completed  from  the  toes 
to  the  knee.  The  plaster  is  cut  out  over  the  abdomen  and  behind  as 
high  as  the  lower  end  of  the  sacrum.  The  pelvic  portion  should  be 
made  very  heavy.  The  patient  should  lie  in  bed  with  the  buttocks  rest- 
ing on  the  bed  and  the  operated  leg  off  of  the  side  of  the  bed  in  order  to 


10  TECHNIQUE  OF  OPERATIONS 

maintain  the  hyperext ended  position  of  the  hip  (see  figure  24),  unless 
he  is  placed  on  a  Bradford  frame  held  above  the  bed.  If  there  is  too 
much  pressure  on  the  chest,  the  leg  is  lowered.  In  this  way  there  is  no 
danger  of  loosing  the  hyperextended  position  of  the  leg.  Plaster  should 
be  split,  "bi-valved,"  on  both  sides  of  the  leg  and  foot  and  tied  with  a 
wet  gauze  bandage  or  strapped  with  webbing  straps  or  adhesive  plaster. 
It  is  often  necessary  to  use  sedatives  for  the  first  five  days,  when  the 
correction  has  been  considerable.  They  should  be  given  rather  than 
withheld  for  pain  or  restlessness.  After  five  days  a  well  padded  plaster 
will  be  perfectly  comfortable.  The  patient  lies  on  his  back  for  five  weeks 
and  then  is  sat  up  in  the  original  plaster.  In  sitting  the  good  leg  is 
flexed,  the  other  reaches  over  the  edge  of  the  bed.  At  the  end  of  the 
sixth  or  seventh  week  the  patient  is  stood  up  a  little  at  a  time  and 
finally  at  the  end  of  the  eighth  or  ninth  week  he  walks  on  the  good  leg 
with  crutches  and  assistance.  The  plaster  is  cut  so  that  the  knee  por- 
tion may  be  removed  posteriorly  and  allow  a  little  motion  here.  When 
he  is  able  to  stand  without  showing  any  weakness,  the  plaster  is  re- 
moved and  a  light  fresh  plaster  applied  with  the  patient  standing  and 
holding  on  to  his  crutches.  This  position  is  preferable  to  one  lying 
down  when  the  plaster  is  to  be  used  for  locomotion. 


CHAPTER  III 

OTHER   OPERATIONS   IN    CASES    OF   PARTIAL   OR   TOTAL   PARALYSIS   ABOUT 

THE    HIP 

11.  Operation  for  Partial  or  Total  Paralysis  of  the  Hip  Muscles. 
Flail  Hip. — When  there  is  a  total  paralysis  of  the  hip  muscles,  very 
extensive  apparatus  is  necessary  unless  some  operation  can  be  done  to 
insure  the  stability  at  the  hip.  An  arthrodesis  between  the  head  and 
acetabulum  or  between  the  inner  side  of  the  trochanter  and  the  pelvis 
and  acetabulum  may  be  done.  The  latter  is  preferable.  No  arthrodesis 
should  be  advised  in  small  children  and  care  should  be  taken  not  to 
injure  the  epiphysis  in  older  children.  An  arthrodesis  of  the  hip  is  very 
satisfactory.  To  obtain  union,  the  operation  requires  some  care.  The 
inner  side  of  the  trochanter  previously  denuded  is  more  apt  to  give  good 
ankylosis  than  an  attempted  arthrodesis  between  the  head  and  acetab- 
ulum. In  extensive  paralysis  the  bone  repair  is  poor  on  account  of 
the  weak  impoverished  condition;  the  larger  surface  makes  the  union 
more  probable.  The  operation  is  an  easy  one  on  account  of  the  few 
muscle  fibers  in  paralytic  cases.  After  operation  the  hip  should  be  pro- 
tected until  weight  bearing  is  satisfactory. 

Where  the  paralysis  is  partial,  silk  ligaments  may  be  applied  as 
described  below  to  balance  the  strong  muscles.  When  the  paralysis  is 
extensive  they  are  not  useful. 

12.  Operation  for  Arthrodesis  of  the  Hip  in  Paralytic  and  in  Osteo- 
Arthritic  Conditions. — For  a  flail  hip  or  a  dislocated  flail  hip  an  arthro- 
desis is  often  done  in  order  to  make  apparatus  unnecessary.  In  osteo- 
arthritis it  is  done  to  relieve  pain.     See  section  40.     See  figures  62-64. 

An  incision  is  made,  starting  from  the  anterior  superior  spine  and 
extending  downward  to  the  upper  edge  of  the  great  trochanter  and  then 
down  along  its  anterior  border.  Other  incisions  may  be  used  (see 
Arthrotomy  at  the  Hip).  The  tensor  fascia  femoris  is  separated  from 
the  gluteus  minimus.  The  latter  is  detached  from  its  insertion  on  the 
great  trochanter.  The  leg  is  forcibly  abducted.  The  capsule  is  incised 
from  above  downward  and  from  within  outward,  parallel  to  its  fibers. 
The  incision  is  carried  from  close  to  the  anterior  inferior  spine  to  the 
intra  trochanteric  line.  The  head  is  brought  out  into  the  wound  and 
the  acetabulum  and  head  inspected.  The  capsule  is  removed  at  its 
distal  attachment  to  the  neck  and  trochanter  by  slowly  rotating  the 
hip  inward  and  then  outward.  Three  or  four  strands  of  heavy  silk  are 
placed  in  the  detached  edges  of  the  tough  capsular  fibers,  each  strand 
quilted  in  and  out  of  the  capsule,  two  long  ends  for  each  strand.  These 
are  clamped  and  reattached  later  to  the  femur.    The  operator  may  now 

17 


18  TECHNIQUE  OF  OPERATIONS 

either  denude  the  acetabulum  of  articular  cartilage  and  the  head  of  the 
femur  likewise;  or  the  acetabulum  above  and  below  is  chiseled,  making 
a  long  surface  of  denuded  bone  ready  to  receive  the  inner  side  of  the 
denuded  trochanter.  Should  the  latter  method  be  adopted,  the  head 
and  neck  of  the  femur  are  removed  and  a  vertical  wedge  removed  from 
the  inner  side  of  the  femur,  shaped  to  give  abduction.  This  wedge 
may  be  one-half  or  three-fourths  of  an  inch  thick  at  the  top  and  taper- 
ing to  a  sliver  below.  The  exposed  bone  on  the  inner  side  of  the  femur 
should  fit  the  denuded  pelvic  bone  intimately.  The  operator  should 
note  the  position  of  the  patella  in  order  to  keep  the  femur  in  the  proper 
position  during  the  removal  and  fitting  of  the  bony  surfaces.  The  capsule 
of  the  joint  having  been  partly  saved,  the  four  pair  of  heavy  silk  strands 
previously  quilted  into  the  capsule  are  now  utilized  and  fasten  the  femur 
snugly  to  the  pelvis,  the  muscles  are  brought  tightly  over  this  with  kan- 
garoo tendon  or  double  chromic  catgut  sutures  number  one,  the  skin 
with  continuous  chromic  catgut  suture  number  00.  A  small  gauze  pad 
is  placed  over  the  wound,  then  sterile  sheet  wadding.  A  nail  or  a  bone 
peg  may  be  used  to  hold  the  trochanter  to  the  pelvis. 

The  plaster  and  after  treatment  is  the  same  as  that  described  follow- 
ing osteotomy  of  the  femur  for  hip  flexion. 

When  an  arthrodesis  at  the  hip  is  done  on  account  of  muscular  paral- 
ysis, if  the  abductors  and  the  adductors  are  still  strong,  it  is  necessary 
often  to  lengthen  or  tenotomize  or  do  a  myotomy  of  these  muscles  de- 
pending on  their  condition. 

13.  Silk  Ligaments  at  the  Hip  for  Paralysis  of  the  Abductors. — 
When  the  adductors  are  unopposed,  walking  is  often  very  difficult  in 
paralytic  condition.  An  arthrodesis  or  silk  ligament  may  be  used  to 
make  apparatus  unnecessary. 

The  patient  lies  on  his  back,  cushions  or  sand  bags  are  placed  under 
the  buttock  of  the  affected  side  holding  the  patient  firmly  and  giving 
access  to  the  posterior  superior  spine  and  allowing  manipulation  of  the 
hip. 

Where  the  abductors  of  the  hip  are  completely  paralyzed  and  a  flail 
condition  of  the  hip  is  present,  silk  ligaments  are  placed  from  the  crest 
of  the  ilium  to  the  great  trochanter. 

Incisions  are  made  two  inches  long  over  the  crest  of  the  ilium  and  at 
right  angles  to  it  (see  figure  33),  at  about  ten  different  points.  The 
bone  is  drilled,  double  strands  of  heavy  braided  silk  number  eighteen 
are  inserted  and  looped  through  the  crest  of  the  ilium  (see  figure  34). 
Two  strands  will  come  from  each  insertion.  Another  incision  is  made 
vertically  over  the  great  trochanter  extending  one  inch  above  and  three 
inches  downward  over  this  bone.  The  eight  or  ten  double  silk  strands 
which  have  been  attached  to  the  crest  of  the  ilium  are  brought  down  by 
a  tendon  carrier,  subcutaneously  to  the  great  trochanter.  These  strands 
are  quilted  into  the  fibrous  tissues  overlying  the  trochanter  or  the 
bone   is  drilled   and .  these   silk  strands  inserted   into   three  or  four 


OTHER  OPERATIONS  IN  PARALYSIS  ABOUT  THE  HIP       19 


drill  holes  and  tied.  Before  these  strands  are  tied,  the  leg  should  be 
abducted  slightly  in  order  to  give  good  leverage  to  the  strands  and 
prevent  adduction.  The  operator  should  notice  the  position  of  the 
patella  and  of  the  anterior  spines,  adjusting  the  leg  according  to  these 
landmarks  and  tying  the  strands  separately  to  maintain  the  desired 
position.  In  sitting,  the  patient  abducts  the  leg  slightly.  If  the  leg  is 
shorter  than  the  other  it  should  be  held  by  the  silk  in  a  few  more  de- 
grees of  abduction  than  if  the  legs  were  equal.  The  leg  should  be  ab- 
ducted ten  degrees  more  than  the  desired  position  in  abduction;  the 
degree  depends  on  the  amount  of  shortening.     The  deep  tissues  are 


Fig.  33. — Points  of  incision 
for  silk  ligaments  at  the  hip. 
Lange.  A,  Crest  incision.  B, 
Trochanter  incision. 


Fig.  34. — Silk  ligaments 
applied  in  partial  flail  condi- 
tion of  the  hip,  from  the  ilium 
to  the  trochanter. 


brought  together  with  interrupted  chromic  catgut  sutures  number 
00,  the  subcutaneous  fat  with  interrupted  chromic  catgut  sutures 
number  00.  A  plaster  of  Paris  spica  is  applied  from  the  nipple  line  (see 
figures  28,  29)  down  to  the  toes,  maintaining  the  position  of  the  hip 
with  no  strain  on  the  ligaments  for  four  or  five  months.  After  that 
time  slight  strains  are  allowed  by  removing  the  plaster  for  short  in- 
tervals twice  a  day,  gradually  increasing  as  the  case  allows.  The 
plaster  of  Paris  bandage  and  apparatus,  length  of  bed  treatment, 
and  other  treatment  is  the  same  as  that  described  after  osteotomy  for 
hip  flexion. 
A  leather  spica  may  be  substituted  for  the  plaster  after  eight  weeks. 


CHAPTER  IV 


INCISION,    PUNCTURE,    ARTHROTOMY   AT   THE    HIP 


14.  Exposure  of  the  Ilium.  Sprengel's  Incision. — Sprengel's  incision 
at  the  hip  may  be  used  for  reaching  the  ilium  in  case  of  fracture  or 
disease.  The  patient  lies  on  the  opposite  side  from  that  to  be  operated 
on.  An  incision  is  made  along  the  crest  of  the  ilium  starting  at  the 
posterior  superior  spine  extending  forward  to  the  anterior  superior 
spine  (see  figure  35).    All  of  the  muscles  are  detached  subperiosteally 

and  peeled  off  of  the  crest.  This  incision  is 
joined  at  its  middle  by  a  vertical  one  ex- 
tending down  to  the  top  of  the  great  tro- 
chanter. The  skin,  fat,  fascia,  muscle  and 
periosteum  are  all  lifted  in  one  layer  and 
retracted  downward  and  anteriorly  and 
posteriorly  from  the  bone,  exposing  the 
ilium  and  its  crest.  By  means  of  a  sharp 
osteotome  the  periosteum  may  be  lifted 
from  the  inner  side  of  the  crest  and  expose 
the  inner  surface  of  the  ilium. 

15.  Exposure  of  the  Sacro-Iliac  Joint. — 
To  expose  the  sacro-iliac  joint  for  disease,  a 
curved  incision  is  made,  two  or  four  inches 
forward  of  the  posterior  superior  spine  of 
the  ilium  and  extending  along  the  crest 
of  the  ilium  backward  and  curving  down- 
ward along  the  border  of  the  sacrum  (figure 
36).  A  skin  incision  made  extending  one 
inch  external  to  the  border  of  the  sacrum 

-Sprengel's     incision        -n    1  rj.uij.i-  1 

along  the  crest  of  the  ilium  with  a  will  be  more  comfortable  to  he  on  when 
vertical  portion  from  its  middle  healing  and  will  give  as  good  exposure  when 
down  to  the  top  of  the  trochanter.  retracted.  If  the  surgeon  prefers  he  may 
use  a  curved  incision  extending  from  a  point  one  inch  external  to 
the  third  or  fourth  lumbar  spinous  process  curving  outward  beyond 
the  posterior  spine  of  the  ilium  on  the  affected  side  and  downward  to 
the  top  of  the  coccyx.  The  incision  is  carried  through  the  skin  and  fat 
in  one  layer.  The  flap  is  dissected  back,  exposing  the  fascia.  The  out- 
line of  the  sacrum  is  easily  made  out  and  the  dissection  continued  as 
indicated. 

In  disease  of  the  bone  in  the  sacro-iliac  region  the  abscess  may  extend 
over  the  front  of  the  sacrum  as  well  as  the  side.  It  should  be  wiped 
out  with  gauze  strips  and  the  carious  bone  removed;  small  bits  being 

20 


INCISION,  PUNCTURE,  ARTHROTOMY  AT  THE  HIP         21 


removed  at  a  time.  Tubes  are  placed  from  the  surface  to  all  the  de- 
pendant portions;  gauze  is  used  to  keep  the  soft  tissues  and  skin  well 
gaped  for  ten  days  after  which  the  tubes  are  shortened  and  finally  all 
removed  in  about  ten  days  more,  or  sooner  in  mild  cases. 

16.  Arthrotomy. — A  knowledge  of  the  important  routes  of  approach 
to  the  joints  will  facilitate  any  joint  exploration,  the  removal  of  foreign 
bodies,  the  repair  of  traumatic  conditions,  the  adjustment  of  difficult 
fractures,  the  reduction  of  old  and  difficult  dislocations,  to  mobilize 
joints  where  motion  is  partially  or  totally  lost,  and  to  restrict  or  stiffen 
the  joint  as  in  certain 
paralytic  conditions,  to 
relieve  and  thoroughly 
drain  suppurative  con- 
ditions; a  knowledge  of 
the  important  routes  of 
approach  to  the  joint  is 
very  important.  For 
each  case,  the  operator 
will  select  the  incision 
best  suited  for  the  in- 
dividual  condition. 
Each  joint  will  be  con- 
sidered separately  but 
joint  operations  should 
never  be  hastily  con- 
sidered ,  and  should  be 
avoided  by  anyone  not 
familiar  with  the  best 
surgical  technique. 

In  all  operations  on 
the  joints,  the  incision 
should  be  made  down 
to  the  synovial  mem- 
brane and   made  large  T 

,     ,     c  .         jig.  6b. — Incision  for  reaching  the  sacroiliac  articulation. 

enough  before  opening 

the  synovial  cavity.  All  bleeding  should  be  stopped  and  the  synovial 
membrane  carefully  opened.  The  joint  structures  should  be  tampered 
with  as  little  as  possible,  the  synovial  membrane  brought  together  sep- 
arately and  the  layers  over  it  closed  carefully  in  order  not  to  disturb  the 
function  of  the  periarticular  tissues.  Unnecessary  separation  of  the  tissue 
layers  is  to  be  avoided.  Tendons  should  be  left  in  their  sheath.  Any  lig- 
aments that  must  be  cut  should  be  loosened  periosteal^,  in  order  that 
they  may  be  readily  replaced.  Early  motion  should  be  the  rule,  gentle 
at  first,  and  gradually  increased. 

17.  Arthrotomy  at  the  Hip. — Arthrotomy  at  the  hip  is  necessary 
sometimes  for  recent  or  old  dislocations,  for  congenital  dislocation  of 


22 


TECHNIQUE  OF  OPERATIONS 


case. 


the  hip,  separation  of  the  epiphysis,  compound  fractures,  some  simple 
fractures,  acute  arthritis  of  infancy,  other  suppurative  conditions,  hip 
disease,  acetabular  disease,  to  relieve  ankylosis  from  various  causes,  for 
the  purpose  of  arthroplasty,  arthrodesis  or  excision.  The  surgeon  will 
have  to  select  the  incision  best  suited  to  the  necessities  of  the  individual 
When  a  good  view  of  the  acetabulum  is  necessary,  the  antero- 
lateral incision  has  advantages.  The  anterior  incision 
is  often  sufficient  for  the  treatment  of  dislocations  and 
for  drainage. 

In  suppurative  cases  an  anterior  incision  or  the  first 
portion  of  the  antero-lateral  incision  may  be  used, 
supplemented  by  a  posterior  incision.  Wherever  the 
condition  is  extensive  and  very  acute,  this  incision 
should  be  supplemented  also  by  an  anterior  incision. 

Where  there  is  acetabular  disease,  the  antero-lateral 
is  preferable,  supplemented  by  its  second  part  when 
necessary. 

Whenever  the  suppurative  condition  is  extremely 
severe  and  acute  nothing  but  the  most  thorough  drain- 
age should  ever  be  attempted.  For  this  purpose  an 
anterior  incision  combined  with  an 
antero-lateral  and  a  posterior  will 
hip   incision    along  give    thorough    drainage.      It   is    a 


the  outer  border  of  curi0us  fact  that  in  suppurative  con- 

the  sartorius.  i...  r  ±r.  j.    v     1  1  i_       1 

ditions  ot  the  acetabulum  and  head 
the  anterior  incision  is  the  one  to  close  last  and  to 
discharge  longest. 

For  an  arthroplasty,  Dr.  Murphy's  U-shaped  in- 
cision will  give  the  most  satisfactory  exposure  (see 
Arthroplasty  at  the  Hip).  In  obscure  joint  derange- 
ment following  injury,  an  antero-lateral  will  give  the 
best  view  of  the  joint. 

In  dislocation  of  the  hip,  an  anterior  incision  or  an 
antero-lateral  incision  may  be  used.  In  very  difficult 
cases  and  cases  of  long  standing  the  antero-lateral  is 
preferable. 

18.  Anterior  Incision  (see  figures  37,  38). — The 
incision  begins  one  inch  below  the  anterior  superior 
spine,  extends  five  inches  downward  between  the  sar- 
torious  and  the  tensor  fascia  femoris  following  the 
outer  border  of  the  sartorious.  The  rectus  is  retracted  inward  and 
the  tensor  fascia  femoris  outward.  The  attachments  of  the  sartorious, 
tensor  fascia  femoris  and  rectus  femoris  may  be  freed  subperiosteally 
from  the  ilium  as  described  under  fasciotomy.  This  however  will  not 
be  necessary  in  most  instances.  When  the  muscles  are  retracted  the 
capsule  is  opened  parallel  to  its  fibers. 


Fig.     38. — Line     of 
anterior  incision. 


INCISION,  PUNCTURE,  ARTHltOTOMY  AT  THE  HIP        23 


19.  Antero-lateral  Incision  (see  figures  39,  40).— The  incision  is 
made  from  the  anterior  superior  spine  to  the  top  of  the  great  tro- 
chanter, then  downward  along  the  anterior  border  of  the  femur.  The 
incision  is  made  through  the  skin  and  fat  down  to  the  muscle  fibers. 
The  coarser  fibers  of  the  gluteus  medius  are  recognized  and  separated 
from  the  finer  fibers  of  the  tensor  fascia  femoris;  the  two  muscles  are  sep- 
arated by  blunt  dissection  and  retracted,  exposing  the  capsule.  If  nec- 
essary the  gluteus  medius  may  be  detached  from  its  attachment  to  the 
trochanter.    The  capsule  is  incised  in  the  lines  of  its  fibers  and  retracted. 


Fig.  39.— Antero- 
lateral incision,  from 
the  anterior  spine  to 
the  trochanter  then 
downward  along  the 
femur  separating  the 
tensor  fascia  femoris 
gluteus  medius. 


Fig.  40. — Antero-lateral  in- 
cision. Lateral  view.  When 
more  room  is  needed  the  an- 
tero-lateral incision  is  ex- 
tended backward  along  the 
dotted  lines. 


Fig.  41. — A.  Glutues 
medius;  B,  Tensor 
fascia  femoris;  C,  Sar- 
torius;  D,  Quadri- 
ceps. 


All  bleeding  should  be  stopped  before  opening  the  synovial  membrane. 
If  it  is  necessary  to  inspect  the  acetabulum  the  femur  is  rotated  out 
allowing  the  capsule  to  be  detached  from  the  femur  subperiosteally 
as  far  inward  as  possible.  The  femur  is  next  rotated  inward  while  the 
capsule  is  being  freed  posteriorly.  When  this  has  been  accomplished 
two  to  four  silk  strands  are  attached  separately  to  the  capsule  along  its 
detached  margin.  The  ends  of  the  silk  are  left  long  and  clamped  out- 
side the  wound.  This  will  facilitate  retraction  of  the  capsule  and  later 
recognition  of  its  edges,  when  the  operation  is  completed.  If  it  is  nec- 
essary to  dislocate  the  head,  the  hip  is  flexed  and  abducted  and  out- 
wardly rotated,  allowing  the  ligamentum  teres  to  be  cut.     When  the 


24 


TECHNIQUE  OF  OPERATIONS 


purpose  of  the  operation  is  drainage,  a  pair  of  forceps  or  a  sound  can  be 
used  as  an  aid  in  making  an  opening  posteriorly  after  the  head  is  dislo- 
cated. As  the  blunt  instrument  protrudes  under  the  skin,  from  within 
outward  an  incision  is  made  over  it,  giving  a  point  for  posterior  drainage. 
The  antero-lateral  incision  is  a  very  good  one  for  dislocations  as  well  as 

/,  plastic  operations.      It  is  often  supplemented  by  a 

y  horizontal   incision  extending   from   the   trochanter 

backward;  see  below. 

20.  Antero-lateral  Incision  with  Second  Part  for 
more  Extensive  Exposure  of  the  Hip  (see  figures  40, 
41,  42).— The  antero-lateral  incision  may  be  supple- 
mented b}r  an  incision  about  four  inches  long  starting- 
two  inches  below  the  top  of  the  trochanter  directly 
backward  from  the  first  incision.  This  extends 
through  the  skin  and  fat.  As  the  trochanter  comes 
into  view  its  top  is  removed  by  means  of  a  sharp 
osteotome,  or  a  Gigli  saw,  the  operator  being  care- 
ful to  leave  enough  bone  so  as  not  to  weaken  the 
neck.  The  Gigli  blade  is 
passed  behind  the  top  of 
the  trochanter  by  means 
of  a  long  heavy  needle 
threaded  with  silk  to 
which  the  saw  chain  is  at- 

Fig    42-Antero-    t      fa  d> 
lateral  incision  with 

horizontal  incision.  The  gluteus  mechus,  the 
Anterior  view.   The  perif0rmis,    and     gluteus 

cross  line  shows  the         •    •  j    ,       1      i  1 

line  of  incision  used  minimus  are  detached  and 
where  more  room  is  retracted  upward,  giving 
required.  a   g0od   exposure    of   the 

joint.  Before  detaching  the  trochanter,  two 
double  silk  strands  may  be  placed  in  the 
tendons  of  the  gluteus  medius  and  two  in 
the  fascia  below  so  that  in  closing  the  wound 
the  top  of  the  trochanter  may  be  readily  re- 
placed by  means  of  the  silk  sutures;  or  the 
bone  may  be  drilled  and  sutures  placed 
ready  for  use  later  when  replacing  the  top 
of  the  trochanter.    Some  operators  prefer  From  the  junction  of  the  pos- 

to  nail  the  top  of  the  trochanter  into  place    terior  and  middle  third  of  the 
...  .,  .,i  i  •  crest  of  the  ilium  to  below  the 

with  a  wire,  nail  or  with  a  bone  or  ivory  top  of  the  trochanter. 
peg  or  bone  screw. 

21.  Posterior  Incision  (see  figure  43). — An  incision  is  made  ex- 
tending upward  from  the  trochanter  to  the  crest  of  the  ilium,  starting 
two  inches  below  the  top  of  the  great  trochanter  to  a  point  on  the  crest 
about  three  inches  forward  of  the  posterior  superior  spine.    This  in- 


INCISION,  PUNCTURE,  ARTHROTOMY  AT  THE  HIP        25 


cision  is  carried  down  through  the  skin  and  fat,  exposing  to  the  muscle 
layer. 

For  simple  drainage  the  muscle  fibers  of  the  gluteus  maximus  may  be 
separated  and  some  of  the  fibers  cut.  Or,  the  aponeurosis  of  the  gluteus 
maximus  is  separated  from  the  great  trochanter,  also 
some  of  the  fibers  of  the  gluteus  minimus,  and  the 
muscles  are  retracted,  exposing  the  capsule  of  the 
joint.    This  is  separated  parallel  to  its  fibers. 

22.  U-Shaped  Incision  used  by  Dr.  Murphy  for 
Arthroplasty. — Dr.  Murphy  recommends  a  U-shaped 
incision  for  Arthroplasty  at  the  hip,  the  sides  of  which 
are  about  five  inches  long  and  three  inches  apart.  He 
starts  above  the  trochanter  and  one  inch  behind.  His 
incision  extends  two  inches  below  the  top  of  the 
trochanter.  The  trochanter  should  be  in  the  centre  of 
the  U.  This  will  give  a  piece  of  fascia  lata  four  inches 
wide  and  five  inches  long  to  use  as  a  flap.  The  anterior 
portion  of  the  U  starts  two  inches  below  and  one  inch 
anterior  to  the  trochanter  and  extends  up  five  inches 
in  a  straight  line  to  the  anterior  superior  spine  of  the 
ilium.  The  skin  and  fat  and  fascia  are  retracted  up- 
ward, exposing  the  tro- 
chanter, the  top  Of  Which  is  TTFlG:  44.-Anterior 
,       • ,  i     • ,  i  U-mcision,  from  be- 

removed  With  its   mUSCleS  at-    low  the  anterior  su- 

tached,  the  operator  being 
careful  not  to  weaken  the 
attachment  of  the  neck  in 
removing  the  top  of  the 
trochanter. 

23.  Anterior  U-Incision  (see  figures  44, 45). — 
Dr.  Brackett  recommends  the  use  of  a  U-shaped 
incision;  the  inner  incision  extends  downward 
from  just  below  the  anterior  superior  spine  five 
inches,  keeping  just  external  to  the  artery,  then 
three  to  four  inches  across  the  leg  and  five 
inches  upward  anterior  to  the  trochanter.  The 
sartorius  is  recognized  and  retracted  inward, 
with  the  rectus,  the  tensor  fascia  femoris  out- 
ward. 

24.  Internal  Lateral  Incision.  Adductor  In- 
cision for  Exposure  of  the  Hip. — The  hip  is 

flexed  ninety  degrees,  abducted  ninety  degrees  and  outwardly  rotated 
ninety  degrees.  An  incision  five  inches  long  is  then  made  along  the 
border  of  the  adductor  longus.  The  adductor  longus  is  retracted  in- 
ward and  the  pectineus  outward.  This  incision  is  sometimes  recom- 
mended in  dislocations  as  it  is  the  most  direct  route  to  the  ilio  femoral 


perior  spine  down- 
ward just  outside 
the  artery,  then  out- 
ward and  upward 
along  the  trochanter. 
Brackett. 


Fig.  45.— Side  view  of  U- 
shaped  incision.  (See  fig- 
ure 44.) 


26  TECHNIQUE  OF  OPERATIONS 

ligament  which  is  often  the  obstacle  preventing  a  successful  reduction  of 
the  dislocation. 

25.  Arthrotomy  for  Fractures  About  the  Hip. — The  necessity  of 
immediate  operation  in  fracture  about  the  joints  depends,  as  in  other 
fractures,  on  the  acuteness  of  the  local  and  general  reaction.  When 
these  do  not  contra  indicate  immediate  operation,  certain  fractures 
about  the  joint  may  require  treatment  by  the  open  method.  Among 
these  are  fractures  of  the  patella,  fracture  of  the  olecranon,  certain 
fractures  of  the  surgical  neck  of  tha  humerus,  and  certain  fractures  of 
the  neck  of  the  femur,  all  compound  fractures,  even  when  the  protrusion 
of  the  bone  has  been  extremely  slight,  all  fractures  that  cannot  be  main- 
tained, or  where  apposition  is  impossible,  many  fractures  combined 
with  dislocation,  articular  fractures  with  pieces  locking  or  limiting  the 
joint  action.    See  figures  67  to  70. 

Where  there  is  a  great  deal  of  trauma  and  in  multiple  fractures  and 
in  cases  where  there  is  a  great  deal  of  shock  all  that  can  be  done  is  to 
immobilize  the  parts  until  a  favorable  time  for  operation.  In  selecting 
a  suitable  time  for  operation  the  surgeon  must  remember  that  when  it 
is  found  necessary  to  operate  on  a  fracture  if  there  is  no  immediate  contra 
indication,  the  sooner  it  is  done  the  better.  Where  there  is  tremendous 
swelling  the  surgeon  should  always  wait.  All  cases  should  be  operated 
on  that  show  no  union  after  three  months  of  good  treatment. 

Methods  of  treating  the" individual  fracture  cannot  be  considered  in  a 
limited  space  like  this.  The  writer  has  described  the  routes  of  approach 
to  the  different  joints  and  the  technique  of  these.  This  will  enable  the 
surgeon  from  his  knowledge  of  fractures  to  select  the  route  best  adapted 
for  the  individual  treatment  required  and  when  necessary  two  or  more 
incisions  may  be  used.  A  knowledge  of  the  technique  will  enable  the 
surgeon  to  work  rapidly  in  reaching  the  fracture  on  which  he  expects 
to  spend  time. 

26.  A  Method  of  Treating  Overlapping  Fractures. — Where  the  bones 
overlap,  an  excellent  method  of  treatment  is  one  suggested  to  the  writer 
many  years  ago  by  Dr.  Edward  Martin  of  Philadelphia.  In  the  opera- 
tion when  the  surgeon  has  reached  the  fracture  the  ends  are  freed.  A 
tough  tape  or  webbing  is  used  ten  or  twelve  feet  long  and  is  sterilized. 
The  two  ends  of  the  tape  are  tied  together,  a  loop  of  the  tape  is  placed 
over  the  distal  end  of  the  bone.  The  other  end  of  the  tape  is  thrown 
over  the  foot  of  the  operating  table,  a  thirty-five  pound  weight 
is  attached  to  this  by  an  assistant.  In  about  five  minutes  the 
bones  will  be  found  to  be  separated  at  least  one  inch.  The  weight  is 
then  held  up  by  a  non-sterile  assistant,  the  tape  taken  off  of  the  end  of 
the  bone  and  clamped  to  the  sheet  on  the  operating  table,  so  that  it  will 
not  slip  away  while  the  surgeon  works  on  the  fracture.  When  the 
muscles  are  in  fairly  good  tone  or  the  overlapping  of  bone  has  been  great, 
it  will  be  found  that  the  bones  will  overlap  again  in  four  or  five  minutes. 
A  reapplication  of  the  tape  will  separate  the  bones  again  for  the  same 


INCISION,  PUNCTURE,  ARTHROTOMY  AT  THE  HIP        27 

length  of  time.  The  end  of  the  lower  bone  should  not  be  cut  or  fresh- 
ened until  all  other  procedures  are  done  which  require  separation  of 
the  bone.  When  these  have  all  been  done  the  end  of  the  bone  over  which 
the  tape  has  been  placed  is  freshened.  After  this  the  tape  should  not 
be  placed  on  the  end  of  the  bone,  but  the  two  ends  allowed  to  come  to- 
gether and  held  by  a  clamp  until  the  operation  is  complete. 

Very  bad  overlapping  fractures  have  been  treated  in  this  way  in  fresh 
cases  without  the  necessity  of  shortening  the  bone.  In  old  fractures 
no  more  bone  need  be  removed  than  is  required  by  the  conical  condi- 
tion of  the  ends  of  the  bone. 

27.  Fractures  of  Long  Standing  Still  Ununited  or  United  with 
Deformity,  Preventing  Function. — In  fractures  of  long  standing  where 
there  is  a  mild  infection,  conservative  treatment  should  be  tried 
first.  When  this  has  been  tried  free  drainage  should  be  established  and 
at  the  same  time  the  ends  of  the  bone  freshened  up  slightly.  Unless  the 
infection  is  marked,  in  many  of  these  cases  when  the  suppuration  dis- 
appears, union  has  also  taken  place.  In  any  case  where  there  has  been 
infection,  no  plastic  operation  should  be  performed  until  infection  has 
been  entirely  absent  for  at  least  nine  months;  a  year  is  safer.  Where 
the  infection  is  very  mild  and  of  long  standing,  during  the  process  of 
treatment  the  patient  may  be  allowed  to  walk  on  the  other  leg  if  the  local 
reaction  is  not  too  great.  Sometimes  he  may  walk  a  little  on  the  af- 
fected leg.  It  is  of  advantage  in  certain  cases  to  use  a  Thomas  knee 
splint  to  take  some  of  the  weight  off  of  the  affected  leg,  the  patient  being 
allowed  to  bear  weight  on  the  ball  of  the  foot,  the  splint  taking  all  the 
weight  off  of  the  heel.  Where  the  x-ray  shows  conical  ends  of  the  bone  it 
is  practically  useless  to  expect  union  without  surgical  interference.  The 
Carrell-Dakin  technique  is  advisable  in  infected  cases.    See  section  323. 

28.  Fractures  of  the  Neck  of  the  Femur  in  the  Young  or  Middle 
Aged. — In  recent  fractures  of  the  neck  of  the  femur,  Dr.  Whitman's 
technique  is  most  satisfactory.  Under  anaesthesia,  manual  or  mechan- 
ical traction  is  applied  to  both  legs.  The  good  leg  is  abducted  to  de- 
termine the  amount  of  abduction  possible.  The  fractured  leg  is  pulled 
on  and  abducted  while  the  surgeon  presses  on  the  trochanter,  reducing 
the  deformity  and  guiding  the  leg  into  extreme  abduction  and  hyper- 
extension,  and  outward  rotation  is  also  corrected.  A  plaster  of  paris 
bandage  is  applied  to  the  thorax,  pelvis,  thigh,  leg  and  foot  holding  the 
hip  in  extreme  hyperextension  and  extreme  abduction;  it  should  fit  well. 
(See  application  of  plaster  for  the  hip  and  thorax.)  A  Bradford  frame 
is  used  under  the  plaster.  A  well  fitting  plaster  enables  the  patient  to 
be  moved  after  the  first  five  days  without  disturbing  the  fracture.  The 
bed  may  be  lifted  at  the  head  to  relieve  any  tendency  to  hypostatic  con- 
gestion. The  leg  of  the  plaster  rests  off  of  the  bed  as  described  for 
plaster  following  osteotomy  at  the  hip.  The  patient  may  be  put  on  a 
bed  rest  at  the  end  of  two  weeks,  if  necessary,  the  well  leg  remains  on 
the  bed;  the  leg  in  plaster  is  off  of  the  side  of  the  bed.    The  after  treat- 


28 


TECHNIQUE  OF  OPERATIONS 


ment  is  otherwise  the  same  as  for  osteotomy  at  the  hip.  The  age  of  the 
patient  must  be  considered.  The  results  are  very  excellent.  However, 
in  the  very  feeble  it  may  take  one  year  before  the  patient  is  able  to  walk 
well,  but  then  it  is  due  to  feebleness  rather  than  lack  of  function.  The 
hyperextensiori  of  the  hip,  the  reduction  of  the  deformity,  the  extreme 
abduction  and  correction  of  the  outward  rotation  will  favor  good  func- 
tion. In  cases  with  osteoarthritis  there  is  some  danger  of  stiffness  with 
any  fracture.  Fractures  of  the  neck  may  be  adjusted  and  nailed  or  bone 
pegged.  In  the  old,  the  fracture  is  often  impacted  and  should  be  dis- 
turbed as  little  as  possible.  The  danger  from  pneumonia  or  hypo- 
static congestion  is  worse  than  the  fracture.  In  younger  subjects,  an 
incision  is  made  and  the  fracture  adjusted.  See  figures  59  to  62.  Trac- 
tion on  the  trochanter  is  made  as  described  for  overlapping  fractures  and 
the  head  and  neck  pegged,  nailed,  wired  or  grafted.  The  trochanter  and 
neck  are  drilled  and  a  tight  prepared  bone  or  other  peg  driven  into  the 
hole  made  by  a  drill  the  size  of  the  peg  and  if  possible  tapered  so  that 
it  may  be  driven  tight.*  The  patient  is  put  up  in  a  long  plaster  spica 
from  the  nipple  line  to  the  toe  and  immobilized  in  bed  for  four  to  five 
weeks,  and  then  gotten  up  with  crutches  and  the  spica  cut  off  below  the 
knee.  Old  fractures  of  the  neck  with  an  excursion  of  the  trochanter 
may  be  adjusted  by  pulling  down  the  leg  as  far  as  possible,  then  cutting 
the  trochanter  to  fit  the  head  or  the  denuded  acetabulum.  This  gives 
a  firm  hip  sometimes  with  forty  to  eighty  degrees  of  motion,  some- 
times very  little  motion.  Walking  is,  however,  much  improved  and 
later  the  other  leg  may  be  shortened  if  the  dif- 
ference is  great  (see  paragraph  42) .  It  should  be 
remembered  as  pointed  out  by  Whitman  that 
full  abduction  and  hyperextension  is  the  best 
position  for  a  recent  fracture  of  the  neck. 

29.  Coxa  Vara.  Operation. — In  operations  for 
Coxa  Vara,  an  anterior  or  antero-lateral  incision 
may  be  used  unless  a  trochanteric  operation  is 
decided  upon.  This  latter  operation  is  the  most 
satisfactory  (see  Subtrochanteric  Osteotomy). 

30.  Incision  for  Exposure  of  the  Sciatic 
Nerve.— An  incision  in  the  median  line  is  made 
three  inches  long  on  the  posterior  aspect  of  the 
thigh  beginning  at  the  fold  of  the  buttock  divid- 
ing the  lower  fiber  of  the  gluteus  maximus  and 
separating  the  tissues  below  this  muscle  by  blunt 
dissection.  The  sciatic  nerve  can  be  felt  with  the 
finger.    A  full  view  of  the  nerve  is  obtained  when 

the  muscles  are  separated  (figure  46). 

31.  Incision   of    the   Adductor   Magnus   Tendon    in   Hip   Opera- 
tions.— In  manipulating  a  dislocated  hip  or  a  shortened  leg  due  to 
*  As  described  by  Hawley. 


Fig.  46. — Incision  for  reach- 
ing the  sciatic  nerve. 


INCISION,  PUNCTURE,  ARTHROTOMY  AT  THE  HIP 


29 


overlapping  fracture  of  long  standing,  it  is  sometimes  necessary  in 
addition  to  having  a  traction  machine  and  in  addition  to  the  opera- 
tion on  the  joint  or  the  fracture,  to  gain  length  in  the  adductor 
magnus  by  a  tenotomy  of  the  tendon  just  above  the  internal  condyle. 

The  tendon  may  be  felt  here.  An  incision  is  made  three-fourths  of 
an  inch  long,  the  finger  readily  recognizes  it,  a  director  hooks  it  up  and 
its  fibers  tenotomized  directly  across  or  by  an  oblique  or  zig-zag  tenot- 
omy. One  suture  will  close  the  incision.  It  is  sometimes  surprising  the 
relief  of  tension  obtained  by  this  procedure  (see  figure  47) . 

32.  Operation  for  Gluteal  Bursitis  (see  figure  48). — An  incision  is 
made  three  inches  long  over  the  great  trochanter  through  the  skin  and 


Fig.  47. — A dductor 
magnus  incision.  Incision 
three-fourths  of  an  inch 
long.  Here  the  tendon 
can  be  hooked  up  and 
tenotomized. 


Fig.  48. — Incision  for  reaching 
the  gluteal  bursa. 


fat  parallel  to  the  femur.  This  is  the  most  convenient  incision  for 
gluteal  bursitis.  The  fascial  portion  of  the  gluteus  maximus  is  raised 
and  the  bursa  will  be  found  under  it.  The  bursa  may  be  dissected  out 
or  incised  and  drained. 

33.  Tapping  the  Hip  Joint.— The  most  scrupulous  aseptic  precau- 
tions are  necessary  both  as  to  the  preparation,  and  the  protection,  of  the 
field  of  the  operation. 

The  trocar  may  be  thrust  just  above  the  great  trochanter  from  the 
side  of  the  patient  directly  inward  or  the  joint  may  be  reached  from  the 
front  external  to  the  sartorius  at  the  same  level  (see  figures  49,  50). 
When  the  head  or  neck  is  reached  the  sharp  point  of  the  trocar  may  be 
withdrawn  and  the  dull  end  used  as  a  probe  to  locate  the  exact  point 


30 


TECHNIQUE  OF  OPERATIONS 


before  using  the  trocar  point  again.  The  neck  is 
reached  easily  and  then  the  head,  further  inward. 
The  trocar  point  is  then  inserted  and  the  joint 
tapped. 

When  there  is  much  effusion  it  is  not  difficult  to 
^*x  I  reach  the  joint.  The  skin  is  drawn  to  the  side 
so  that  the  hole  in  the  skin  and  muscle  will  be 
out  of  line  when  the  needle  is  removed.  If  fluid  is  to 
be  withdrawn,  and  other  solutions  are  to  replace  it, 
the  amounts  should  be  carefully  measured.  Two  good 
graduated  metal  syringes  are  very 
useful.  All  of  their  parts  should  be 
tested  beforehand.  The  trocar  is 
Fig.  49.— Tapping  made  to  enter  the  joint  and  then 
the  hip  from  the  js  connected  with  the  syringe.  As 
little  air  as  possible  should  enter  the 
joint.  The  trocar  should  be  of  large  diameter  as  the 
fluid  may  be  thick  or  flaky.  When  the  patient  is  not 
anaesthetized  for  the  operation  it  is  often  well  to  have 
a  short  flexible  tube  connect  the  trocar  with  the 
syringe.  This  should  be  fastened  at  both  sides  by 
silk  ties  so  that  it  will  not  leak  easily  when  pres- 
sure or  suction  is  used.  If  the  joint  is  to  be  washed  out 
a  definite  amount  of  fluid  is  injected  and  the  return 
measured  in  a  sterilized  measuring  glass. 

Dr.  Murphy  uses  a  formalin  glycerine  solution  as 
follows: — 

Liquor  formaldehyde,  2%  in  glycerine,  about  ten 
drops  of  the  formaldehyde  to  each  ounce  of 
glycerine.  This  acts  very  well  in  infectious  synovitis.  Fig-  50.— Tapping 
But  it  should  not  be  used  in  arthritis  deformans  ^  SS,01^ 
nor  in  old  chronic  arthritis.  The  tapping  may  be  pomt  one-half  way 
done  with  ethyl  chlorid  or  novocaine  adreneline  between  the  top  of 
solution,  1%.  The  solution  should  be  prepared  *h®  artery?1  aT  Pou- 
twenty-four  hours  before  it  is  used  (Murphy).  parts  ligament. 


CHAPTER  V 

OPERATIVE   TREATMENT  IN   CASES   OF  HIP-JOINT   ANKYLOSIS 

34.  Principle  of  Arthroplasty  for  Ankylosis  of  the  Hip. — Ankylosis 
may  be  bony,  cartilaginous  or  fibrous,  it  may  be  periarticular,  liga- 
mentous and  capsular,  or  extra  articular,  that  is,  skin  scars,  tendons, 
fascia,  nerves  and  arteries. 

The  form  of  ankylosis  that  exists  will  determine  the  treatment.  A 
partial  ankylosis  at  certain  points  had  better  not  be  treated  by  an 
arthroplasty. 

Age  must  be  considered,  also  the  general  condition  of  the  patient. 
When  the  ankylosis  is  bony,  cartilaginous  or  fibrous,  arthroplasty  is 
indicated.  When  the  condition  is  periarticular  or  extra  articular,  it 
may  be  treated  by  capsulotomy,  tendon  elongation,  excision  of  exostoses, 
etc. 

Dr.  Murphy  lays  stress  on  the  following  points:  The  principles  of 
asepsis  to  the  finest  detail  are  absolutely  essential.  One  not  familiar 
with  the  best  surgical  technique  should  avoid  arthroplastic  operations. 
The  exposure  of  the  joint  must  be  generous  and  careful.  The  excision 
of  the  ankylosis  must  be  complete.  The  contracted  capsular  ligaments 
and  soft  parts  must  be  freed  and  if  necessary  lengthened.  The  normal 
contour  of  the  joint  should  be  restored  as  near  as  possible.  The  operator 
should  obtain  a  hyper-mobilization  of  the  joint.  The  joint  should  be 
re-shaped  to  give  stability.  The  inter-position  of  material  to  prevent 
reunion  of  the  bone  is  necessary.  The  principle  is  to  separate  the  bones 
and  to  interpose  between  them  material  to  prevent  ankylosis.  The 
best  material  for  this  purpose  is  the  human  pedicle,  composed  of  fat, 
muscle,  fascia,  or  a  combination  of  these. 

When  this  is  not  possible,  a  transplantation  is  made  of  fat  and  fascia 
from  the  trochanter  bursa  region  or  from  the  fascia  lata. 

Material  such  as  ivory,  celluloid,  silver  are  not  good.  Materials  that 
will  not  absorb  or  that  absorb  too  slowly  are  not  desirable. 

During  the  operation  the  soft  parts  should  be  freely  liberated.  Attach 
the  interposing  flap  to  one  bone  only  and  cover  it  completely.  Early 
motion,  that  is,  at  the  end  of  five  to  seven  days  is  necessary  with  or 
without  gas  or  gas  oxygen. 

Dr.  Murphy  records  failures  in  arthroplasty  as  due  to  first,  insuffi- 
cient and  defective  exsection  of  the  capsule  and  ligaments,  second,  in- 
sufficient interposition  of  fat  and  fascia  between  the  separated  bony 
surfaces,  third,  infection,  fourth,  the  sensitiveness  to  pain  on  motion 
after  operation. 

Cases  of  primary  tuberculosis  and  cases  of  recent  infection  that  have 

31 


32  TECHNIQUE  OF  OPERATIONS 

subsided  are  not  suitable  cases  for  arthroplasty.  In  operating,  in  addi- 
tion to  the  usual  protection  of  the  field  of  operation,  after  the  skin  and 
fat  have  been  incised,  towels  should  be  clamped  to  the  edges  of  the  skin. 

35.  Technique  of  Arthroplasty  at  the  Hip. — Dr.  Murphy  recom- 
mends a  U-shaped  incision  for  Arthroplasty  at  the  hip  the  sides  of 
which  are  about  five  inches  long  and  three  inches  apart.  He  starts 
one  and  one-half  inches  above  the  trochanter  and  one  inch  behind. 
The  incision  extends  two  inches  below  the  top  of  the  trochanter. 
The  trochanter  should  be  in  the  centre  of  the  U.  This  will  give  a  piece 
of  fascia  lata  four  inches  wide  and  five  inches  long  for  use  as  a  flap.  The 
anterior  portion  of  the  U  starts  one  inch  below  and  one  inch  anterior 
to  the  trochanter  and  extends  up  five  inches  in  a  straight  line  to  the 
anterior  superior  spine  of  the  ilium.  The  skin  and  fat  and  fascia  are 
retracted  upward,  exposing  the  trochanter,  the  top  of  which  is  removed 
with  its  muscles  attached,  the  operator  being  careful  not  to  weaken  the 
attachment  of  the  neck  in  removing  the  top  of  the  trochanter.  A  large 
heavy  needle  threaded  with  silk  is  passed  behind  the  top  of  the  tro- 
chanter; to  the  silk  is  attached  a  chain  saw.  This  is  used  to  remove  the 
top  of  the  trochanter,  the  obturator  and  pyriformis  muscles  are  de- 
tached and  retracted.  The  capsule  is  separated  subperiosteally  from 
the  neck  of  the  femur,  a  number  of  silk  sutures  with  long  ends  are  placed 
in  the  capsule  so  that  it  may  be  easily  recognized  later  on.  The  long 
ends  are  attached  to  clamps  which  help  to  hold  the  capsule  retracted. 
The  capsule  should  remain  attached  to  the  acetabulum.  A  curved 
chisel  is  used  to  separate  the  head  from  the  acetabulum  following  the 
normal  outlines  of  the  joint,  and  extending  inward  one  inch  between 
the  bones  all  around. 

Dr.  Murphy's  globular  drill  and  cup-shaped  endmill  will  smooth  out 
the  cavity  and  make  a  round  shaped  head  of  the  femur.  The  flap  of 
fascia  and  fat  taken  from  under  the  skin  are  now  placed  inward  and 
sutured  to  the  remnant  of  the  capsular  ligament  or  may  be  covered  over 
the  whole  head  and  neck  of  the  femur.  After  replacing  the  head  in  the 
acetabulum,  the  capsule  is  sutured,  the  trochanter  is  replaced,  the  sep- 
arated obturator  and  pyriformis  muscles  are  reattached.  An  eight  or 
six  pennyweight  nail  is  used  to  hold  the  trochanter  in  place.  The  muscles 
are  brought  together  with  interrupted  chronic  catgut  sutures  number  00, 
the  fat  with  interrupted  chromic  catgut  sutures  number  00,  the  skin 
with  continuous  chromic  catgut  sutures  number  00.  Buck's  extension 
apparatus  is  applied  with  twenty  pounds'  weight  holding  the  leg  in  an 
abducted  position.  The  patient  is  kept  in  bed  for  seven  to  ten  days 
with  this  apparatus.  After  this,  passive  motion  in  flexion  is  introduced 
depending  on  the  amount  of  pain  or  motion.  The  passive  motion  is  used 
daily.  Lateral  motions  are  begun  later  on.  A  removable  splint  or  plaster 
is  applied  for  three  or  four  weeks  and  removed  when  a  fair  degree  of 
motion  is  possible  without  pain  or  great  discomfort.  The  patient  is 
then  allowed  to  get  up  with  crutches  and  swing  the  leg. 


TREATMENT  IN  CASES  OF  HIP-JOINT  ANKYLOSIS 


33 


36.  Operation  for  Deformity  at  the  Hip  with  Joint  Ankylosis.    Hip 
Flexion   and    Adduction    with    or    without    Dislocation   of    the   Hip. 
Operation  for  Coxa  Vara. — Where  the  tissues  have  been  contracted 
about   the   hip   over  a  long  period  of  time  and  the   hip   not   dislo- 
cated, there  is  sometimes  a  fibrous  ankylosis  at  the 
hip  which  maintains  the  position  of  deformity  even 
after  an  operation  is  done  to  relieve  the  contracture 
of  the  soft  tissues.    Often  after  dislocation  a  practical 
ankylosis  exists.    Where  this  ankylosis  is  very  slight 
and  not  due  to  previous  tuberculosis  it  is  advisable  to 
limber  up  the  hip  joint  by  manipulation  as  described 
in  these  pages  elsewhere.   When  the  ankylosis  amounts 
practically  to  an  arthrodesis  or  when  an  arthrodesis 
has  been  done  and  deformity  of  flexion  and  adduction 
have  developed,  it  is  often  advisable 
to  do  a  Gaunt  or  subtrochanteric  os- 
teotomy and  correct  the  deformity. 
Even  when  walking  is  possible  with 
a  flexed  and  adducted  hip,  there  is 
a  tremendous  expenditure  of  energy 
due  to  the  awkward  and  back  strain- 
ing position;  with  this  position  there 
is  often  pain  in  the  hip  and  back 
which  eventually  makes  locomotion 
impossible.     These  conditions   are 
relieved  by  straightening  the  leg  and  should  not  be 
left  till  the  patient  is  disabled.    When  deformity  and 
ankylosis  exists  the  operation  of  choice  is  an  osteot- 
omy.   See  figures  494  to  496. 

37.  Subtrochanteric  Osteotomy,  "  Gant." — When 
under  anaesthesia  (for  operation  on  the  right  hip) 
the  patient  is  placed  on  the  left  side,  the  left  hip 
and  knee  being  flexed  to  add  stability  to  the  position. 
Sand  bags  and  pillows  are  arranged  about  the  chest  to 
prevent  the  patient  from  rolling.  The  operator  stands 
behind  the  patient,  the  skin  being  prepared  and  the 
operative  field  protected.  The  osteotome  is  introduced 
over  the  outer  side  of  the  trochanter  subcutaneously 
with  the  blade  parallel  to  the  line  of  the  femur  about 
one  or  one  and  one-half  inches  below  the  top  of  the 
trochanter.  When  the  periosteum  is  felt  with  the  three,  four  and  five 
cutting  edge  of  the  osteotome,  the  blade  is  turned  so  will  be  cut  in  sue- 
that  it  lies  across  the  bone.  The  bone  is  cut  across  cession^- 
slightly  obliquely  from  without  inward  and  downward,  the  operator  cut- 
ting and  then  feeling,  using  the  osteotome  as  a  probe,  then  cutting  what 
he  feels  with  the  osteotome.    An  open  incision  is  of  no  advantage.    The 


a  »   a  - 

Fig.  51. — Diagram- 
matic cross  section  of 
bone.  Shows  inclin- 
ation of  the  osteo- 
tome when  cutting 
the  anterior  bone 
surface  and  method 
of  holding  it  inclined 
anteriorly. 


X  3  + 
Fig.  52.— Shows 
the  method  of  cut- 
ting the  bone  in  sec- 
tions on  the  anterior 
surface. 


Fig.  53.— Shows 
further  cutting  of  the 
bone  surface  (sections 


34 


TECHNIQUE  OF  OPERATIONS 


bone  is  cut  through  on  its  anterior  surface  inward,  then  another  portion  is 
cut  posterior  to  this,  working  from  without  inward,  and  so  on  backward 
until  the  bone  is  entirely  cut  (figures  57,  59).  When  the  bone  is  cut 
through  this  can  be  determined  by  feeling  with  the  osteotome,  an  as- 
sistant lifting  the  leg  and  gently  abducting  or  rotating  the  femur. 
Crepitus  is  felt  "when  the  bone  is  completely  cut  through.    If  a  very 

little  remains  to  be  cut 
it  will  break  readily  as 
the  femur  is  abducted 
and  rotated.  When  the 
osteotome  is  with- 
drawn, no  sutures  are 
necessary.  A  sterile 
sheet  wadding  pad  is 
placed  over  the  small 
wound.  The  patient  is 
placed  on  a  traction 
machine  after  cutting 

Fig.  54. — Traction  machine  for  operation  on  the  hip  or  ^e  bone  but  preferably 

femur  holding  the  patient  ready  for  plaster  without  change  .         ,          .     .                    . 

of  position.     Traction  rods  in  place.    A,   Rollers  against  Ior  tne  WilOle  operation 

tuberosity  of  the  ischium.    B,  Traction  rod.    Two  like  this,  (see  figures   54    to  59), 

C,  Stand  to  hold  pelvis  off  of  the  table.  an(j     fonfa    Jgo-g     nulled 

evenly  so  that 
the  perineum 
rests  firmly 
against  the  per- 
ineal rods.  The 
left  leg  is  tight- 
ened and  then 
the  right,  the 
muscles  being 
stretched  down 
until  good 
length  is  main- 
tained in  the 
short  leg  and 
about  forty  de- 
grees of  abduc- 


Fig.  55. — Traction  machine  parts.  D,  Leggings.  Two  like  this. 
E,  Pulleys.  Two  sets  of  double  block  pulleys.  H,  Disjointed  traction 
rods.  B,  with  thumb  screws  to  hold  inside  rods.  J,  Rods  that  fit 
inside  the  traction  rods.  The  stand  for  the  thorax  is  similar  to  (C) 
only  broader. 


tion  with  twenty-five  degrees  of  hyperextension  at  the  hip.  This  position 
is  regulated  and  held  by  the  traction  apparatus  during  the  application  of 
the  plaster,  which  should  reach  from  the  axilla  to  the  tip  of  the  toe  of  the 
affected  leg.  For  12  years  the  writer  has  used  the  apparatus  illustrated 
here.  Where  a  Hawley  Table  is  available  this  should  be  used.  The  plas- 
ter extends  a  short  distance  down  the  opposite  leg,  and  should  maintain 
the  hip  operated  on  in  an  abducted  position  of  forty-five  degrees  and 
hyperextended  twenty-five  degrees.     When  the  plaster  is  completed  a 


TREATMENT  IN  CASES  OF  HIP-JOINT  ANKYLOSIS 


35 


window  is  cut  over  the  abdomen  and  the  plaster  is  removed  from  the 
back  of  the  thorax  down  to  the  lumbar  region  and  from   the  side 


fS> 


Fig.  56. — Traction  machine  for  operation  on  the  hip  holding  the  patient 
ready  for  plaster  without  change  of  position.  A,  Rollers  against  tuberosity  of 
the  ischium.  C,  Stand  to  hold  the  pelvis  off  of  the  table.  K,  Extension  used 
to  clamp  thorax  and  to  clamp  pelvic  stand  to  table.  There  are  four  extension 
clamps  like  (K) . 

operated  on  as  far 
as  the  crest  of  the 
ilium  (see  figures  25 
to  29).  This  allows 
abduction  and  hy- 
perextension  but 
not  the  reverse. 
The  surgeon  can  as- 
sure himself  of  the 
abducted  position 
by  feeling  the  an- 
terior spines  when 
the  plaster  is  still 
soft,  and  as  soon  as 
the  plaster  is  cut 
out  he  may  put  his 
hand  through  the 
window  in  the  ab- 
dominal portion  of 
the  plaster  and  as- 
certain the  position  of  the  anterior  superior  spines  in  order  to  be  certain 
that  the  abducted  position  has  been  maintained.  The  patient  and  plaster 
are  placed  on  a  Bradford  frame  and  handled  and  moved  on  the  frame. 
The  patient  is  kept  on  his  back  for  six  weeks,  after  that  he  sits  up  in  the 


Fig.  57.— Traction  machine  for  operations  on  the  hip  hold- 
ing the  patient  ready  for  plaster  without  change  of  position, 
clamps  holding  it  firmly  to  the  table.  A,  Rollers  against 
tuberosity  of  the  ischium.  C,  Stand  to  hold  pelvis  off  of  the 
table.  K,  Extension  used  to  clamp  thorax  stand  and  to  clamp 
pelvic  stand  to  table.  M,  Clamp.  There  are  four  like  this. 
P,  Shows  extension  clamping  pelvic  piece  to  table. 


36 


TECHNIQUE  OF  OPERATIONS 


plaster,  on  the  edge  of  the  bed,  keep- 
ing the  good  leg  in  the  bed,  bending 
the  good  hip.  In  four  days  more  he 
is  allowed  to  stand  on  the  good  leg 
and  encouraged  to  walk  as  soon  as 
his  strength  allows.  When  he  is 
able  to  keep  his  equilibrium  for  fif- 

Fig.   58. — To  prevent  slipping  of    the  .  ..    .  *  . 

plaster.    Method  of  applying  plaster  to  teen  minutes  a  lighter  plaster  is  ap- 
tuberosity  of  the  ischium  by  a  plaster  plied  holding  the  pelvis  and  the  leg 

rope  (X)  over  felt  padding,  using  traction    above     th       knee         Walking    is    en_ 

machine  (see  figure  57) .  ° 

couraged  on  the  operated  leg  in  the 
seventh  week.  A  leather  spica  should  be  used  for  about  a  year  to  pre- 
vent adduction. 


CURVED  OSTEOTOMY  AT  THE  BASE  OF  THE  TROCHANTER 

Dr.  Bracket? s  Modification 

Instead  of  doing  an  oblique  osteotomy,  Dr.  Hoffa  and  Dr.  Brackett 
make  an  open  incision  anteriorly  cutting  the  bone  in  a  curve  from 


Fig.  59. — Shows  rope  (X)  pulled  towards  patient's  shoulder. 

within  outward  and  slide  the  bone  in  this  curve  into  an  abducted 
position. 

Removal  of  a  Wedge  of  Bone 
If  the  operator 
prefers  he  may  re- 
move a  wedge  of 
bone     from     the 
femur,    close    the 
gap  and  cause  ab- 
duction  and    hy- 
perextension.  The 
bone    may   be    — 
sutured    or 
wired  or  an  in- 
lay bone  graft 
used  after  os- 
teotonry.       In 
the  majority  of 

cases  a  simple  osteotomy  is  as  good  as  any  of  the  elaborate  methods. 
In  any  event  the  result  will  depend  on  gaining  and  maintaining 
the  position  by  an  adequate  well  fitting  plaster  of  Paris  bandage. 


Fig.  60. — Shows  the  plaster  applied  over  rope  (X)  and  the  ends 
turned  down  holding  the  pressure  on  the  tuberosity  of  the  is- 
chium. 


Fig.  61. — Represents  the  next  stage  with  the  plaster  rope  (X)  buried 
in  the  plaster. 


TREATMENT  IN  CASES  OF  HIP- JOINT  ANKYLOSIS  37 

The  reader  is  referred  to  other  pages  for  the  detail  in  applying 
a  plaster  of  Paris  after  hip  operations  (see  section  10).  A  good 
traction  machine  and  a  well  applied  plaster  are  essential  for  the  best 
results  after  osteotomies  whenever  extreme  deformity  at  the  hip  exists. 

38.  Operation  for  Coxa  Vara  with  Ankylosis. — A  subtrochanteric 
osteotomy  as  described  above  is  the  simplest  and  an  effective  way  of 
correcting  coxa  vara.  The  removal  of  a  wedge  of  bone  from  the  tro- 
chanter is  more  complicated  and  rarely  necessary. 

The  after  treatment  is  the  same  as  in  osteotomy  at  the  trochanter. 

39.  Osteotomy  at  the  Neck  of  the  Femur. — Osteotomy  at  the  neck 
of  the  femur  to  correct  deformity  here  or  for  coxa  vara  is  sometimes 
indicated.  The  neck  is  reached  through  an  antero-lateral  incision 
from  the  anterior  spine  to  the  top  of  the  trochanter  and  then  extending 
downward  two  or  three  inches  along  the  front  of  the  trochanter.  The 
gluteus  medius  and  tensor  fascia  femoris  are  separated  and  the  neck  is 
easily  reached.  A  drill  may  be  passed  through  the  head  of  the  femur  and 
another  through  the  trochanter.  These  are  placed  firmly  in  the  bone 
and  should  be  placed  parallel  to  each  other.  The  neck  is  cut  with  an 
osteotome  and  the  leg  put  in  the  desired  position.  This  operation  should 
be  done  with  the  patient  on  a  traction  machine  so  that  there  will  not  be 
any  over  riding  of  the  fragments.  If  necessary  a  bone  peg  is  passed 
through  the  trochanter  neck  and  head  of  the  bone  after  correcting  the 
deformity,  the  drill  ends  are  now  used  to  guide  the  position  of  the  head 
and  hold  it  into  place  while  applying  the  bone  graft  or  wire  nail.  The 
drill  should  be  a  little  smaller  than  the  nail  or  graft  or  a  tapered  bone 
peg  may  be  used  as  suggested  by  Dr.  Hawley. 

In  most  cases  of  deformity  of  the  neck,  an  osteotomy  through  the 
trochanter  will  give  the  same  result  as  to  correction  and  will  have  the 
advantage  of  simplicity,  also  the  bone  is  thick  and  heavy  here,  making 
good  repair  an  assured  factor.  The  operation  is  some  distance  from  the 
joint  so  that  it  will  be  injured  as  little  as  possible. 

This  operation  should  be  done  with  a  traction  apparatus  as  described 
in  these  cases. 

The  after  treatment  for  osteotomy  through  the  neck  is  the  same  as 
for  osteotomy  through  the  trochanter. 

40.  Albee  Hip  Operation  in  Osteo-arthritis  for  the  Relief  of  Pain. 
Arthrodesis. — In  osteo-arthritis  at  the  hip,  Dr.  Albee  has  suggested  a 
method  of  obtaining  ankylosis  by  a  partial  excision  in  situ.  This  opera- 
tion is  especially  adapted  to  the  adult  arthritic  case  with  severe  pain  and 
in  no  instance  should  it  be  used  where  there  is  active  disease  or  when 
there  has  been  tuberculosis  or  suppurative  joint  disease. 

An  antero-lateral  incision  is  made,  the  head  exposed,  but  not  dis- 
located, its  upper  and  inner  surface  chiselled  away  (see  figures  39 
to  44)  in  situ,  also  the  upper  surface  of  the  acetabulum  remov- 
ing a  quadrilateral  piece  of  bone  partly  from  the  head  and  partly  from 
the  upper  acetabulum.    When  this  space  closes  the  bone  should  be 


38 


TECHNIQUE  OF  OPERATIONS 


cut  in  such  a  way  that  the  leg  abducts,  correcting  any  deformity  in 
flexion  or  adduction.  The  operation  may  be  done  rapidly  and  the  patient 
allowed  up  in  two  weeks  with  a  protective  splint,  or  plaster  if  the  hip 
is  sensitive.  In  order  that  motion  of  the  hip  may  not  return,  activity 
of  the  patient  but  not  of  the  hip  is  encouraged  as  early  as  possible. 
Weight  bearing  is  allowed  at  the  end  of  the  fourth  week.  The  activity 
of  the  patient  is  important  as  the  operation  is  rarely  necessary  in  those 


A 

Fig.  62.— Dr.  Al- 
bee's  operation  out- 
line of  bone  to  be 
removed  from  ace- 
tabulum and  head  of 
the  femur. 


B 

Fig.  63.— Bone  re- 
moved allowing  ab- 
duction and  full 
extension  when  the 
bony  surfaces  come 
together. 


Fig.    64.  —  Position 
favoring  ankylosis. 


Fig.   65. — Method    of    drilling  •  the    bone    on    either    side.     The   dotted    lines 
represent  drill  holes  on  the  other  side. 


Fig.  66. — Side  view  showing  method  of  drilling  the  bone  alternately  on  one 
side  and  the  other. 

under  fifty  years  of  age,  and  then  only  as  a  means  of  relieving  pain  by 
causing  ankylosis  in  a  favorable  position.     See  figures  62,  63,  64. 

41.  Operation  for  Separation  of  the  Epiphysis  at  the  Hip. — In 
separation  of  the  head  at  the  epiphysed  line,  the  antero-lateral  incision 
is  the  easiest  method  of  approach  when  operation  is  indicated. 

In  fractures  of  the  neck  or  intra  capsular  fractures  when  operation 
is  indicated,  the  antero-lateral  incision  is  the  most  satisfactory.  It 
may  be  necessary  in  these  cases  to  insert  a  drill  in  the  head  of  the  bone 
and  use  the  drill  tip  as  a  handle  to  control  it  while  the  fragments  are 


TREATMENT  IN  CASES  OF  HIP-JOINT  ANKYLOSIS  39 

being  adjusted.  A  bone  graft  or  a  peg  or  a  long  nail  may  be  used  to  fix 
the  fracture.     See  section  28. 

42.  Adjusting  Legs  of  Unequal  Length. — When  the  legs  are  very- 
unequal  in  length,  the  longer  leg  may  be  shortened. 

An  incision  four  inches  long  is  made  laterally  or  anteriorally,  separating 
the  fibers  of  the  muscles  and  exposing  the  femur  at  about  its  middle. 
The  bone  to  be  removed  is  marked  above  and  below  allowing  the  leg 
to  be  three-eighths  or  one-half  inches  longer  than  its  fellow.  The  bone 
is  cut  with  a  Gigli  saw  or  a  sharp  osteotome;  the  latter  method  requires 
less  exposure  and  less  disturbance  of  the  tissues. 

The  femur  is  cut  through,  then  each  end  is  brought  out  of  the  wound 
and  sawed,  the  amount  removed  from  each  end  carefully,  measured  by 
a  sterile  steel  ruler.  The  bone  sawed  straight;  or  one  end  sawed  wedge- 
shaped  and  the  other  like  an  inverted  wedge  to  fit  it;  or  each  end  may  be 
cut  like  a  long  step  so  that  they  overlap  and  are  held  by  a  bone  screw, 
suggested  by  Gallie,  the  bone  drilled  with  a  screw  tap,  which  corresponds 
to  the  screw.  A  number  14  screw  tap  and  screw  are  used.  The  bone 
is  adjusted  and  sutures  placed;  coaptation  splints  are  applied  over  sterile 
sheet  wadding  and  a  long  plaster  of  Paris  applied  over  this.  The  patient 
is  kept  in  bed  four  or  five  weeks  and  is  allowed  to  walk  on  the  plaster, 
after  that  with  crutches.  When  walking  is  easy  the  plaster  is  gradually 
omitted. 


CHAPTER  VI 


OPERATIONS    IN    SUPPURATIVE    CONDITIONS   ABOUT   THE   HIP 


43.  Suppurative  Conditions  at  the  Hip  Joint. — In  suppurative 
conditions  at  the  hip  joint  an  anterior  incision  may  be  used.  If  the 
disease  is  extensive  or  very  acute  this  should  be  combined  with  an  ante- 
rior lateral  incision  and  a  posterior.    A  single  incision  is  rarely  enough. 

Tubes  are  placed  to  the  joint  from  each  incision;  gauze  is  used  to  gap 
the  corners  and  make  them  round. 

When  the  acetabulum  is  extensively  diseased  and  the  condition  is 
progressively  growing  worse,  the  head  should  be  dislocated  and  the 
acetabulum  drained  and  a  large  opening  made  through  it.  The  bone 
anterior  to  the  acetabulum  below  the  anterior  spine  may  be  chiselled 
away  with  the  softened  diseased  parts  of  the  acetabulum.  While  this 
may  be  indicated  in  adults,  in  children  the  worse  cases  of  bone  disease 
will  often  recover  in  time,  following  good  drainage  and  without  radical 
measures  applied  to  the  bone.  In  all  cases  good  drainage  should  be 
established  first  and  any  radical  measures  applied  to  the  bone  should 
be  reserved  for  those  cases  where  good  drainage  is  not  sufficient.  See 
section  323,  Carrell-Dakin  technique. 

44.  Excision  of  the  Hip  in  Suppurative  Conditions. — The  hip  is 
approached  as  described  for  arthrodesis  (see  section  12).     The  amount 

IV1 


Fig.  67. — Heavy  bent  wire  frame.  Wire 
splint  for  fracture  of  the  femur  in  infants. 
The  frame  is  covered  with  canvas  as  de- 


Fig.  68. — Showing  patient  in  position. 


scribed  for  the  Bradford  frame.     The  head    0f  bone  to  be  removed  will   depend 

ly  ^  "fitJftSSSSl  on  the  amount  of  disease  present. 

45.  Methods  and  Principles  of 
Drainage  in  Acute  Non-tubercular 
-A  small  suppurative  focus  without 
virulence  or  active  constitutional  disturbance  should  be  drained  by  a 
suitable  incision,  wiped  out  with  gauze,  a  tube  placed  to  its  deepest 
part  and  the  soft  tissues  gaped  with  gauze. 

40 


under  the  hips. 

legs  lifting  the  hips  very  slightly  off  of  the 

frame  as  shown  in  figure  68. 

Suppurative  Joint  Disease.    Hip.- 


OPERATIONS  IN  SUPPURATIVE  CONDITIONS 


41 


When  there  is  a  great  deal  of  constitutional  disturbance  drainage  and 
counter  drainage  should  always  be  the  rule;  if  the  bone  is  involved 
this  should  be  opened  and  counter  opened  as  shown  (figures  65,  66).  The 
pus  cavities  in  the  soft  tissues  should  be  wiped  out.  No  extensive  bone 
operation  should  be  done  otherwise.  The  bone  should  be  drained  with 
tubes  to  the  remote  portions  and  the  muscle,  fat,  and  skin  gaped  by 


c 


z> 


Fig. 


69. — Heavy  bent  wire  frame  holding 
the  knees  flexed. 


Fig.  70. — Bent  wire  frame  for  fracture  of 
the  femur  in  infants.  The  frame  is  made  as 
described  in  67.  The  leg  wires  are  bent  at  the 
knee,  three  to  five  inches  beyond  the  flexed 


gauze.     These  operations  are  done  knee.    Two  soft  folded  towels  (represented  in 

quickly    and    should     not    be    pro-  black)  one  for  each  leg  are  placed  behind  the 

/           /                      .                  .             ^  upper  third  of  the  tibia  and  fastened  to  the 

longed,   but  efficient  drainage  and  frame  lifting  the  hips  off  of  the  frame.    A 


counter  drainage  should  be  estab- 
lished unhesitatingly.  It  is  rarely 
necessary  to  do  more  at  this  time. 


third  and  fourth  soft  folded  towel  is  placed 
over  the  front  of  the  lower  third  of  each  tibia 
to  steady  the  leg  and  help  hold  the  hips  off 
of  the  frame.  A  fifth  and  sixth  soft  towel  is 
If  there  is  a  marked  sequestra  P^ced  above  the  knee  and  fastened  to  the 
-  . .        ■  i  •       i        iii  i     frame.       I  he  towels  are  marked  in  black. 

formation  this  should  be  removed, 

but  this  had  better  not  be  done  at  the  time  of  instituting  drainage 
when  the  patient  is  nearly  exhausted  from  an  acute  process.  Any 
future  operation  made  necessary  should  give  good  drainage  and  the 
removal  of  the  sequestra  if  separated. 

Any  extensive  non-tubercular  suppurative  bone  disease  about  the 
hip  should  be  drained  by  an  antero-lateral  and  a  posterior  incision  or  by 
an  anterior  and  a  posterior  or  by  all  three.  If  the  patient  is  very  ill  and 
the  abscess  not  easily  located  an  anterior,  an  antero-lateral  and  a  poste- 
rior incision  should  be  made  very  rapidly  and  good  drainage  established. 
The  anterior  is  usually  the  last  to  close,  in  spite  of  the  more  dependent 
positions  of  the  other  two. 

In  very  ill  cases  the  operation  should  be  rapid  with  short  anaesthesia 
but  in  these  cases  large  incisions  and  always  counter  incisions  should  be 
insisted  upon.  Excision  and  removal  of  parts  of  the  bone  may  be  done 
later. 

Any  chronic  suppurating  process  should  be  well  drained  and  counter 
drained,  the  pockets  in  the  tissues  well  opened  and  wiped  out  and  the 
diseased  bone  well  drained.  Large  incisions  should  be  made  with  tubes 
to  all  dependent  parts  and  large  gauze  pads  used  gaping  the  wounds  for 
at  least  ten  days;  after  that  the  tubes  and  wicks  are  shortened.  This 
method  of  treatment  is  usually  very  successful.  It  does  not  necessitate 
the  constant  reapplication  of  drains,  so  discomforting  to  the  patient. 
Irrigations  should  not  be  used  in  the  after  treatment.    The  gauze  should 


42  TECHNIQUE  OF  OPERATIONS 

be  placed  around  rather  than  over  the  wounds.  The  hip  is  held  fixed 
by  placing  the  patient  on  a  Bradford  frame  with  traction  or  by  means 
of  a  plaster  of  Paris  bandage  or  an  old-fashioned  Thomas  hip  splint. 
It  should  always  be  immobilized.  See  Carrell-Dakin  Technique,  sec- 
tion 323. 

46.  Acute  Arthritis  of  Infancy. — The  incision  for  drainage  in  acute 
arthritis  of  infancy  is  the  antero-lateral  incision  without  its  second  part. 
As  soon  as  it  is  possible  to  make  a  diagnosis,  an  incision  should  be  made 
down  to  the  capsule  in  which  a  very  minute  incision  is  made  and  a  tube 
introduced.  Immediate  drainage  is  all  that  is  necessary  in  this  condi- 
tion. This  will  relieve  the  tension  in  the  capsule  and  render  spontaneous 
dislocation  unlikely.  For  tenderness  or  swelling  of  the  hip  due  to  sup- 
purative condition,  following  middle  ear  disease,  scarlet  fever  or  other 
acute  infections,  drainage  is  indicated  as  soon  as  a  diagnosis  can  be  made. 

Immobilization  by  sand  bags  with  the  patient  on  a  Bradford  frame 
is  all  that  is  necessary.  In  a  few  cases  a  wire  splint  may  be  used  as 
shown  in  figures  68  to  70. 

47.  Osteomyelitis. — In  osteomyelitis  an  operation  should  be  done 
as  early  as  possible  after  making  the  diagnosis.  In  sub-acute  cases,  in- 
cision and  drainage  is  all  that  is  necessary.  Whenever  incising  for 
abscess,  all  the  pockets  should  be  opened  and  if  the  abscess  is  large, 
counter  incisions  are  made  at  dependent  portions.  The  pus  pockets 
should  be  opened  freely,  wiped  out  with  gauze,  irrigated  and  wiped  out 
again  with  gauze.  Curetting  should  be  avoided  excepting  for  the  re- 
moval of  sinuses  in  the  skin.  In  cases  with  sinuses  it  is  often  better  to 
excise  them.  Perforated  rubber  tubing  should  be  placed  to  drain  the 
deepest  portion  of  each  pocket.  The  skin,  fat  and  superficial  muscle 
layers  should  be  made  to  gap  by  means  of  gauze  drains.  At  the 
end  of  ten  days  the  gauze  is  removed  and  the  tubes  shortened.  The 
tubes  are  gradually  drawn  out  a  little  each  day,  or  two,  until  not 
used.  This  method  makes  the  repeated  reapplication  of  drains  and 
wicks  unnecessary  as  the  wound  will  gap  of  itself  and  close  from  the 
bottom  if  the  surgeon  has  been  careful  to  make  large  incisions. 

Where  the  periosteum  is  found  destroyed  or  the  pus  under  the  peri- 
osteal layer,  the  bone  should  be  opened  by  means  of  a  large  drill  or  a 
small  gouge.  Where  this  is  necessary,  the  incisions  should  be  large  and 
a  counter  incision  should  be  made  on  the  other  side  of  the  bone  with  a 
hole  made  in  the  bone  a  little  above  or  a  little  below  the  hole  on  the 
opposite  side  (figure  65).  These  holes  in  the  bone  should  open  up  the 
medullary  cavity.  They  should  alternate  on  one  side  and  the  other  as 
far  up  and  down  as  the  disease  is  suspected.  When  the  abscess  is  very 
great  and  the  bone  involvement  is  large  a  number  of  good  size  holes 
should  be  made  with  a  Burr  drill  or  a  curved  gouge  on  both  sides  of  the 
bone  as  shown  in  figure  66.  The  wound  should  be  gaped  widely; — 
the  skin,  fat  and  superficial  muscle  held  wide  open  by  large  gauze  drains. 
The  tubes  should  reach  from  the  surface  to  the  deepest  portions  of  the 


OPERATIONS  IN  SUPPURATIVE  CONDITIONS  43 

abscess  cavity.  Splints  should  always  be  applied  to  immobilize  the 
limb.  They  should  be  placed  so  that  they  will  not  interfere  with 
the  dressing.  In  some  instances  it  is  better  to  apply  the  plaster  with 
large  windows  and  ropes  or  to  use  a  Bradford  frame  and  traction  to  give 
stability  as  shown  in  figure  453.  The  dressings  should  be  done  every 
day  or  twice  a  day,  depending  on  the  foul  condition  of  the  discharge. 
If  the  odor  is  excessive  chlorinated  soda  dressing  should  be  used  diluted, 
1/i,  V3  or  1/i  U.  S.  P.  strength.  The  gauze  drains  should  remain  for  at 
least  ten  days  without  being  disturbed.  When  removed  granulations 
will  be  formed  under  them  in  such  a  way  as  to  keep  the  wound  open 
without  applying  drains.  Irrigation  may  be  used  at  the  time  of  the 
operation  and  the  wound  thoroughly  wiped  out  with  gauze  afterwards. 
No  irrigation  or  probing  or  application  of  wicks  will  be  necessary  if  the 
first  drains  are  left  in  long  enough.  After  the  first  ten  days  the  tubes 
are  shortened  gradually  until  they  are  not  needed. 

In  severe  cases  where  the  patient  is  unconscious  or  delirious  the  bone 
should  always  be  opened,  three  or  four  holes  on  either  side  made  with 
a  good  size  Burr  drill  or  a  gauge.  In  no  case  should  the  incision  be 
made  on  one  side  of  the  leg  only  in  severe  cases.  No  tight  packing  should 
be  used  as  this  interferes  with  good  drainage.  Where  sequestra  have 
formed  they  should  be  removed.  An  x-ray  should  be  taken  whenever 
possible  to  determine  the  position  of  the  disease  (unless  the  case  is  ur- 
gent and  an  immediate  x-ray  is  not  obtainable). 

In  cases  of  long  standing  that  are  sub-acute  at  the  time  of  first  exam- 
ination, where  the  bone  is  riddled  with  holes  over  an  extremely  long 
area,  it  is  impossible  often  to  remove  the  dead  bone  satisfactorily  without 
removing  all  the  bone.  In  these  cases  free  incision  down  to  the  bone  with 
frequent  openings  into  the  bone  as  described  above,  will  allow  the  septic 
process  to  run  its  course  and  the  sequestra  to  gradually  separate.  We 
have  had  some  cases  in  which  the  lower  third  of  both  femora  were 
riddled  with  holes  and  full  of  sequestra,  the  patient  being  in  no  condition 
for  extensive  operation,  and  yet  not  very  ill.  In  these  cases,  however, 
if  the  surgeon  had  seen  the  patient  in  time  an  early  operation  would 
have  prevented  this  extreme  condition. 

Sometimes  it  is  necessary  to  close  a  large  open  bone  cavity  which  will 
not  heal  over.  Where  the  process  is  distinctly  septic  no  plastic  operation 
should  be  done  without  first  doing  an  operation  to  eliminate  the  septic 
condition.  After  that,  part  of  the  muscle  may  often  be  transferred  over 
such  a  cavity  after  it  is  closed.  In  transferring  a  muscle  over  such  a 
cavity  it  should  be  freely  transplanted  and  held  there  without  tension. 
The  skin  should  be  brought  together  over  the  muscle  and  the  wound 
drained,  as  there  is  apt  to  be  some  inflammatory  reaction. 

Where  sequestra  are  present  it  is  always  desirable  to  remove  them  as 
soon  as  they  have  separated  and  the  involucrum  is  strong  enough  to  act 
as  a  support.  Sequestra  may  be  superficial  or  in  the  medullary  cavity 
or  both.    Where  there  is  a  persistent  sinus  and  a  sequestrum  is  present, 


44  TECHNIQUE  OF  OPERATIONS 

pus  will  continue  to  form  until  the  sequestrum  is  removed.  Cases  dis- 
charging several  years  where  a  sequestrum  is  present  may  close  in  a  few 
weeks  after  removal  of  the  sequestrum. 

In  closing  a  bone  cavity  its  edges  may  be  chiselled  clean,  then  the  bone 
incised  a  short  distance  from  one  edge  and  parallel  to  it,  the  incision  is 
carried  down  to  the  medulla.  This  incision  in  the  bone  is  widened  by 
prying  it  open  and  forcing  the  bone  together,  closing  the  old  cavity. 
This  method  of  closing  an  old  open  bone  cavity  is  sometimes  satisfactory. 
For  the  treatment  of  suppurating  conditions  by  the  Carrell-Dakin  tech- 
nique, see  section  323. 


PART  II— KNEE 


CHAPTER  I 


OPERATIONS  FOR  DEFORMITIES  OF  THE  KNEE 


Fig.  71. — Dr.  Bradford's  position  for 
manipulation  of  the  knee.  The  knee  rests 
on  a  pillow.  , 


48.  Operative  Manipulation  of  the  Knee. — In  manipulation  of  the 
knee  under  anaesthesia  the  patient  should  lie  on  his  face  with  a  firm 
pillow  (see  figure  71),  or  sand  bag  under  the  lower  end  of  the  femur. 
Where  there  is  very  slight  flexion  of  the  knee  due  to  contracture  of  the 
hamstrings,  the  operator  will  grasp 
the  thigh  near  the  tibia  with  the 
left  hand  and  just  below  the  middle 
of  the  calf  with  the  right.  An  assist- 
ant holds  the  lower  end  of  the  femur 
and  a  second  assistant  steadies  the 
buttock.  In  order  not  to  break  the 
femur  or  the  tibia,  the  first  assistant 
should  hold  the  femur  below  the 
middle  and  the  manipulator  should 
hold  the  tibia  above  its  middle.  The  joint  is  gently  stretched  and  re- 
laxed, the  operator  applying  force  gently  in  a  gradually  increasing  man- 
ner until  considerable  force  is  applied 
and  then  relaxing  until  very  slight  force 
is  used  and  finally  relaxing  entirely.  A 
rhythmic  extension  and  flexion  is  kept 
up.  No  rough  or  forcible  extension  with- 
out a  gradually  increasing  or  gradually 
decreasing  force  should  be  employed.  In 
this  way  a  minimum  amount  of  trauma 
is  caused.  A  joint  that  at  first  will 
seem  almost  impossible  to  extend  will 
often  give  way  and  straighten. 

49.  Operation  for  Flexion  Deformity 
of  the  Knee. — Permanent  flexion  of  the 
knee  may  exist  with  motion  or  without 
motion.  When  there  is  no  motion  the 
knee  is  ankylosed  in  a  flexed  position. 
When  there  is  motion  and  permanent 
flexion,  full  extension  is  impossible.  Complete  flexion  may  also  be  im- 
possible. 

The  treatment  will  of  course  depend  on  whether  the  deformity  is 

45 


Fig.  72. — Dr.  Goldthwait's  genu- 
clast  applied.  A,  Strap  over  the  un- 
der end  of  femur.  B,  Pressure  plate 
at  upper  end  of  tibia  posteriorly. 
C,  Strap  over  lower  end  of  tibia  an- 
teriorly.   D,  Lever  end. 


46  TECHNIQUE  OF  OPERATIONS 

easily  corrected  by  gradual  stretching  under  ether  or  whether  these 
modes  of  treatment  are  undesirable  because  of  the  condition  of  previous 
disease  or  because  of  the  resistant  condition  of  the  flexion.  When  no 
previous  disease  has  existed  if  slight,  the  flexion  is  corrected  by  manip- 
ulation.  Usually  it  is  not  necessary  to  lengthen  or  tenotomize  the  ham- 
strings (see  in  the  pages  tenotomy  and  myotomy  of  the  hamstrings). 

When  the  condition  is  resistant  or  due  to  previous  disease  quiescent 
for  a  long  time,  especially  if  a  fair  degree  of  motion  exists,  an  osteotomy 
and  correction  of  the  deformity  is  a  very  satisfactory  procedure  because 
of  its  ease  and  because  of  the  result  to  the  patient.  This  may  be  done 
when  the  examination  and  x-ray  all  show  that  the  deformity  is  of  long 
standing  or  was  due  to  a  diseased  process  that  has  subsided.  Even  if 
the  motion  is  not  limited  by  bony  ankylosis,  much  trauma  is  necessary 
to  forcibly  straighten  the  deformity  without  osteotomy.  The  trauma 
from  stretching  and  tearing  will  often  give  much  swelling  and  a  stiff 
knee  may  result.  On  the  other  hand,  by  an  osteotomy  all  the  joint 
motion  present  before  operation  is  assured  afterward  with  the  leg 
straight.  It  is  better  to  do  an  osteotomy,  just  above  the  adductor  tu- 
bercle and  straighten  the  knee.  This  is  especially  indicated  if  there  is 
good  motion  in  flexion  beyond  the  permanent  flexion.  The  knee  should 
always  be  hyperextended  a  little  after  such  an  osteotomy.  (See  sec- 
tion 54.) 

In  cases  with  from  twenty-five  to  eighty  degrees  of  permanent  flex- 
ion with  motion  beyond  this,  there  will  be  comparatively  little  trauma 
and  a  very  good  functional  result  from  this  operation.  When  con- 
siderable flexion  exists,  accompanied  by  subluxation,  then  a  genuclast 
is  often  necessary  to  obtain  the  best  results  (see  figure  72). 

Slight  permanent  flexion  is  sometimes 
due  to  a  curled  semilunar  cartilage  or  in- 
flammatory changes  due  to  injury  of  the 
Fig.  73.— Flexed  knee  with  subluxa-  cartilage.      When  this   has  existed    for 

some  time,  force  should  not  be  used,  but 
the  inflammation  allowed  to  subside  or  the  cartilage  removed  com- 
pletely as  described  elsewhere  in  these  pages. 

50.  Operation. — Tendon  Lengthening  to  Correct  Knee  Flexion. — 
When  the  knee  flexion  is  due  entirely  to  short  hamstring  muscles  these 
may  be  lengthened  by  one  of  the  methods  described  under  tendon 
lengthening  either  in  the  muscular  or  preferably  in  the  tendonous  parts 
of  the  muscle,  the  tendons  being  split  diagonally  or  by  the  zig-zag 
method  and  sutured.  In  simple  cases  careful  stretching  under  ether 
is  all  that  is  required. 

When  the  contracture  is  due  to  spastic  rigidity  of  the  flexors  of  the 
knee  it  is  usually  better  to  tenotomize  the  tendons  by  open  method. 
If  the  contracture  is  of  long  standing,  careful  manipulation  with  or 
without  genuclast  may  be  necessary.  If  there  is  much  joint  ankylosis 
an  osteotomy  low  down  on  the  femur  may  be  necessary  as  described  in 


OPERATIONS  FOR  DEFORMITIES  OF  THE  KNEE  47 

these  pages.  When  the  tendons  are  lengthened  and  this  is  sufficient, 
the  knee  is  held  slightly  hyperextended  in  plaster  for  six  weeks,  after 
that  a  caliper  is  used  until  locomotion  is  satisfactory.  The  caliper  is 
gradually  omitted  as  the  leg  becomes  strong  and  the  surgeon  is  able  to 
assure  himself  that  no  recontracture  is  taking  place. 

The  muscles  should  be  exercised  in  flexion  and  extension  from  the 
sixth  week  on.  Usually  the  caliper  is  worn  for  two  hours  once  a  day  to 
stretch  out  the  tissues.  If  they  tend  to  contract  the  daily  time  for  wear- 
ing the  splint  is  increased. 

51.  Correction  of  Subluxation  of  the  Tibia  by  Manipulation. — If 
the  subluxation  of  the  tibia  is  very  slight  it  may  be  corrected  by  manip- 
ulation at  the  same  time  as  the  permanent  knee  flexion.    ' 

The  patient  is  anaesthetized  and  turned  over  on  his  face.  He  is  then 
drawn  down  so  that  the  knee  is  at  the  edge  of  the  table  and  a  pillow 


Fig.    74. — A    method    of    correcting  Fig.   75. — Method   of  using  the 

subluxation  of  the  tibia  by  sheet  trac-         lower  leg  as  a  lever  to  correct  sub- 
tion;  sheets  applied  first  stage.  luxation  of  the  tibia,  second  stage. 

is  placed  under  the  knee.  An  assistant  holds  the  femur  close  to  the  knee 
and  a  second  assistant  holds  his  weight  over  the  buttock.  The  operator 
flexes  and  extends  the  knee  gently  increasing  the  extension  and  forcing 
the  tibia  forward  until  the  knee  will  slightly  hyperextend.  The  patient 
is  then  turned  over  and  a  well  padded  and  fitting  plaster  is  applied  as 
high  as  possible  on  the  thigh  and  including  the  foot,  holding  the  knee 
hyperextended. 

The  plaster  is  split  on  either  side  and  may  be  loosened  if  the  swelling 
is  great.  The  patient  should  be  kept  quiet  for  three  days  and  in  bed  for 
a  week,  after  that  he  is  up  if  the  swelling  and  local  symptoms  have 
subsided.  He  is  then  allowed  to  walk  with  the  plaster.  When  walk- 
ing is  easy  a  caliper  splint  is  used  during  the  day  and  a  plaster  at 
night. 

As  the  knee  becomes  strong  without  tendency  to  recontract,  the 
caliper  splint  is  omitted  more  and  more  and  used  only  two  hours  a  day 
for  one  year.  If  the  knee  tends  to  flex,  the  caliper  will  have  to  be  worn 
longer  each  day.  The  plaster  at  night  is  omitted  after  the  surgeon  has 
assured  himself  that  the  knee  does  not  recontract  during  the  day.  When 
the  flexion  and  subluxation  are  considerable  a  genuclast  should  be  used 
to  correct  the  deformity. 


48 


TECHNIQUE  OF  OPERATIONS 


Manipulation  of  the  Knee  and  Correction  of  Subluxation  with 
Genuclast. — When  there  is  subluxation  of  the  tibia  (see  figure  73)  the 
Goldthwait  genuclast  is  used  (see  figure  72). 

This  apparatus  is  applied  with  the  knee  flexed  preferably  at  right 
angles.    The  deformity  will  sometimes  decide  the  position  of  the  knee. 

One  strap  rests  over  the  end 
of  the  femur,  a  second  strap 
is  placed  over  the  front  and 
lower  third  of  the  tibia  and 
a  padded  plate  is  forced  by 
a  twin  screw  against  the 
upper  end  of  the  tibia.  By 
increasing  the  pressure  on 
the  upper  end  of  the  tibia, 
subluxated  tibia  is 
brought  forward;  when  this 


Fig.  76. — Method    of   maintaining   hyperextension 
of  the  knee  or  other  correction  of  deformities  at  the    the 
knee  during  the  application  of  plaster. 


is  accomplished  the  genuclast  is  reapplied  as  follows : 

The  strap  which  did  rest  under  the  lower  end  of  the  femur  is  now 
placed  on  the  lower  end  of  the  femur  anteriorly;  the  padded  plate  and 
the  strap  remain  the  same.  The  pressure  is  now  reapplied  on  the 
upper  end  of  the  tibia  and  the  genuclast  used  to  straighten  the  knee 
until  it  is  slightly  hyperextended.  A  plaster  of  Paris  is  then  ap- 
plied from  the  toes  to  the  groin  holding  the  knee  slightly  hyper- 
extended. In  straightening  a  knee  in  plaster  any  pressure  with  the 
hand  should  be  above  the  patella,  not  over  it;  forcing  the  patella  on 
the  bone  is  undesirable.  It  should  be  remembered  also  that  any  pres- 
sure or  denting  of  the  plaster  remains  as  a  prominence  pressing  into 
the  patient. 

In  correcting  deformities  at  the  knee  it  is  important  that  sufficient 
correction  should  be  done  to  obtain  hyperextension  of  the  knee  easily 
maintained  after  the  manipulation.  This  hyperextension  should  be  so 
completely  obtained  that  no  force  will  be  required  in  holding  the  knee 
in  this  position  during  the  application  of  the  plaster. 

After  the  operation  the  patient  is  kept  quiet  for  about  three  weeks 
depending  on  the  amount  of  swelling.  After  that  he  is  allowed  to 
walk  on  the  leg  a  little  each  day.  At  the  end  of  six  weeks,  as  soon 
as  he  walks  well  with  the  plaster  on  the  knee,  a  caliper  splint  is  applied 
(figure  475),  which  should  be  used  at  first  night  and  day  or  during  the 
day  and  replaced  by  a  plaster  at  night.  At  the  end  of  three  months 
the  caliper  splint  which  hyperextends  the  knee  easily  is  omitted  for  part 
of  each  day.  When  the  knee  shows  no  tendency  to  recontract,  the  ap- 
paratus is  omitted  at  night  at  first  and  then  omitted  entirely,  ex- 
cepting for  two  hours  each  day.  It  should  be  used  two  hours  each 
day  at  least  one  year.  Recontracture  often  takes  place  very  grad- 
ually and  is  not  readily  noticed.  Any  tendency  to  recurrence  of  the  per- 
manent flexion  at  the  knee  should  be  treated  by  longer  or  continued 


OPERATIONS  FOR  DEFORMITIES  OF  THE  KNEE  49 

application  of  the  caliper  splint.    Exercise  should  be  used  to  strengthen 
the  leg  and  aid  in  locomotion. 

In  many  cases  where  the  permanent  flexion  at  the  knee  has  been  pro- 
longed, especially  when  subluxation  is  extreme  and  has  existed  for  many 
years,  there  is  a  fibrinous  union  of  the  upper  end  of  the  tibia  to  the  femur. 
Often  this  can  be  overcome  only  by  an  open  operation.  In  these  cases 
two  incisions  should  be  made  parallel  to  each  other,  one,  one  inch  to  the 
outer  side  and  the  other  one  inch  to  the  inner  side  of  the  patella  about 
five  inches  long.  The  adhesions  are  relieved.  They  are  often  found 
most  resistant  on  the  posterior  part  of  the  femur.  When  they  are  re- 
lieved the  straightening  of  the  knee  is  carried  out  as  indicated  above. 
Care  should  be  taken  not  to  cut  the  lateral  ligaments.  If  necessary  they 
may  be  removed  subperiosteal^  from  their  attachments  to  the  femur 
or  tibia  but  not  cut  across. 

52.  Another  Method  of  Correcting  Subluxation. — In  certain  cases 
when  it  is  necessary  to  straighten  a  knee  and  a  genuclast  is  not  available, 
two  folded  sheets  will  sometimes  answer  in  correcting  the  subluxation 
(see  figures  74  and  75).  The  patient  lies  on  his  abdomen;  a  twisted  sheet 
is  placed  between  his  legs  and  drawn  up  tight  against  the  tuberosity 
of  the  ischium.  The  ends  extend  one  toward  the  shoulder  in  front  and 
the  other  behind.  They  are  brought  together  at  the  head  of  the  operating 
table  and  a  webbing  strap  is  passed  through  the  loop  and  then  fastened 
to  the  head  of  the  operating  table.  This  prevents  the  patient  from 
sliding  down  off  of  the  operating  table  when  the  leg  is  being  pulled.  A 
second  sheet  is  applied  around  the  upper  end  of  the  tibia  which  is  slightly 
flexed  and  carried  down  to  the  foot  of  the  table  (see  figure  74). 
This  second  sheet  is  made  fast  and  held  by  the  first  assistant.  The 
operator  flexes  the  knee,  which  motion  forces  the  upper  end  of  the  tibia 
downward.  The  operator  then  extends  the  knee.  The  first  assistant 
takes  in  the  slack  in  the  sheet  to  accommodate  itself  to  the  extended 
knee  and  as  the  operator  flexes  the  knee  again,  the  tibia  is  thus  forced 
further  into  place.  This  process  is  repeated  and  a  great  deal  of  force 
may  be  used  until  the  subluxation  of  the  tibia  is  overcome. 

In  cases  where  there  is  a  partial  ankylosis  due  to  an  old  diseased  process 
which  has  subsided,  it  is  undesirable  to  use  force  in  straightening  the 
knee.  It  is  also  better  not  to  do  an  arthroplasty.  In  these  cases  it  is 
better  to  do  an  osteotomy  through  the  femur,  just  above  the  adductor 
tubercle  as  described  elsewhere  in  these  pages.  In  some  cases  beside 
the  flexion  there  is  a  knock  knee  or  bow  leg.  Where  the  patient  is  young, 
it  is  possible  to  bend  the  leg  at  the  epiphysis  in  the  manipulation  and  to 
correct  both  the  flexion  and  bowing  at  the  same  time.  If  this  is  unde- 
sirable an  osteotomy  is  done  and  the  correction  made. 

53.  Operation  for  Knock  Knee  and  Bow  Leg. — For  correction  of 
knock  knee  and  bowing  at  the  knee,  elaborate  operations  and  removal 
of  bone  wedge  are  not  frequently  necessary. 

Where  the  patient  is  an  adult  and  the  knock  knee  or  bow  leg  is  over 


50  TECHNIQUE  OF  OPERATIONS 

fifty  degrees,  a  wedge  of  bone  should  be  removed  instead  of  doing  an 
osteotomy.  In  other  cases,  excellent  results  are  obtained  by  a  simple 
osteotomy  which  is  the  operation  of  choice.  This  operation  is  not  com- 
plicated and  may  be  done  rapidly.  For  bowing  at  the  knee  or  knock 
knee,  the  operation  on  the  bone  is  the  same  as  that  described  for  knee 
flexion.  When  there  is  bowing  of  the  tibia  and  fibula  a  simple  sub- 
cutaneous osteotomy  of  these  bones  with  over-correction  of  the  deformity 
is  all  that  is  usually  required. 

If,  however,  the  bowing  is  anterior  or  very  acute,  a  small  wedge  of  bone 
must  be  removed;  the  bone  heals  without  being  fastened  together.  A 
tenotomy  of  the  tendon  Achilles  should  always  be  done  when  the  de- 
formity is  in  the  lower  leg.  The  after  treatment  is  the  same  as  for 
osteotomy  at  the  knee. 

54.  Correction  of  Flexion  Deformity  of  the  Knee  by  Osteotomy  of 
the  Femur. — The  patient  lies  on  his  back,  the  knee  flexed  at  right 
angles;  the  operator  stands  on  the  side  of  the  leg  to  be  operated  upon. 
A  sand  bag  is  placed  under  the  knee,  the  adductor  tubercle  is  felt  through 
the  skin.  The  osteotome  is  entered  at  the  inner  side  of  the  leg  just  over 
the  tubercle  until  it  reaches  the  tubercle  with  the  blade  parallel  to  the 
femur.  The  operator  prevents  the  slipping  of  the  skin  under  the  osteo- 
tome by  placing  the  thumb  and  forefinger  of  the  left  hand  on  either  side 
of  the  adductor  tubercle,  the  thumb  anterior,  the  index  finger  posterior. 
In  stretching  the  skin  with  these  fingers  which  are  kept  only  a  quarter  of 
an  inch  apart,  it  is  very  easy  for  the  osteotome  to  incise  the  tense  skin 
without  slipping.  As  soon  as  the  periosteum  can  be  felt  by  the  cutting 
edge  of  the  osteotome,  the  operator  turns  the  cutting  edge  at  right 
angles  to  the  bone  so  that  it  will  lie  across  the  femur.  The  osteotomy 
should  be  done  in  the  flat  portion  of  the  femur  and  not  in  the  round 
position  (figures  494  to  496). 

55.  Technique  of  Osteotomy  of  the  Femur  for  Flexion  Deformity 
of  the  Knee. — The  knee  should  be  flexed  at  right  angles  for  the  opera- 
tion in  order  to  avoid  the  vessels  and  nerve  close  to  the  bone.  The 
operator  in  using  an  osteotome  should  learn  to  cut  and  then  to  feel  and 
then  to  cut  what  he  feels  with  the  osteotome,  rapidly.  In  this  way  the 
osteotome  is  used  as  a  probe,  and  as  a  cutting  instrument.  Some  op- 
erators prefer  to  cut  the  anterior  edge  of  the  femur  and  then  to  place 
the  osteotome  back  of  this  and  cut  another  layer  repeating  the  process 
layer  by  layer,  progressing  toward  the  back  of  the  bone.  The  osteotome 
in  cutting  inclines  forward  and  cuts  the  bone  as  marked  in  figures  52,  53. 
The  osteotome  inclines  forward  again  and  cuts  next  as  shown  in  fig- 
ure 54.  Cutting  the  bone  close  to  the  adductor  tubercle  prevents  the 
antero-posterior  deformity  so  often  seen  above  the  knee,  when  the 
osteotomy  is  done  too  high.  The  bone  is  in  a  better  line  than  when  the 
osteotomy  is  done  low  down.     See  figure  494. 

No  suture  is  necessary  in  the  small  hole  made  by  the  osteotome.  The 
knee  is  now  straightened  and  the  deformity  corrected.    If  it  is  a  bowing 


OPERATIONS  FOR  DEFORMITIES  OF  THE  KNEE  51 

at  the  knee,  the  leg  should  be  put  up  in  very  slight  knock  knee.  If  the 
osteotomy  is  done  for  a  knock  knee,  it  should  be  put  up  in  a  very  slight 
bow  leg  position.  In  all  osteotomies,  as  soon  as  the  bone  is  cut  through, 
the  leg  should  be  held  very  carefully  by  an  assistant  and  no  jar  allowed. 
Manipulation  of  the  knee  should  not  be  done  when  an  osteotomy  is  con- 
templated as  it  will  add  to  the  trauma  and  the  motion  which  exists  is 
apt  to  be  lost  in  consequence.  Sterile  sheet  wadding  is  placed  around 
the  leg  at  the  region  of  the  osteotomy  and  the  whole  leg  covered  with 
sheet  wadding  from  the  toes  to  the  groin.  A  well  fitting  plaster  is  applied 
immediately  and  held  in  position  until  hard. 

56.  The  Application  of  a  Plaster  of  Paris  Bandage  After  Operation 
or  Manipulation  of  the  Knee. — To  facilitate  the  correction  of  knock 
knee  or  bow  leg  and  at  the  same  time  to  obtain  a  slight  hyperextension 
of  the  knee  during  the  application  of  plaster,  the  following  method  is  of 
service  in  very  muscular  individuals  or  when  much  force  is  necessary. 
The  leg  having  been  covered  with  sheet  wadding  from  the  toes  to  the 
groin,  a  heavy  felt  pad  is  placed  just  above  the  knee,  a  double  four  inch 
bandage  is  spread  over  this  pad  and  its  four  ends  carried  down  to  a  leg 
or  cross  bar  on  the  operating  table  and  tied  there  (see  figure  76).  The 
operator  can  then  slightly  hyperextend  the  knee  and  correct  the  bowing 
or  the  knock  knee  during  the  application  of  the  plaster  (figures  77,  78). 
When  the  plaster  has  hardened  the  bandage  is  cut  away  from  its  attach- 
ment. In  cases  where  correction  of  knee  deformity  has  been  done 
the  plaster  should  extend  high  on  the  thigh.  It  should  grasp  both  ends 
of  each  bone  and  fit  the  thigh  well  and  fit  the  leg  and  foot  well.  Only  in 
this  way  can  the  full  correction  be  maintained. 

57.  Plaster  for  Holding  the  Knee. — The  plaster  should  fit  holding 
the  upper  and  lower  part  of  the  femur  and  the  upper  and  lower  part  of  the 
tibia.    The  over-correction  is  maintained. 

In  correcting  bowing  at  the  knee  and  knock  knee,  the  plaster  should  be 
applied  with  the 
knee  slightly  hy- 
perextended.  The 
plaster  is  applied 
from  the  toes  to 
the  groin  and  split 
on  either  side. 

58.  After  Treat- 
ment and  a  Sim- 
ple    Method     of 

Preventing  Rota-  Fig.  77. — Plaster  rope  to  prevent  rotation  of  the  plaster  after 
tion      Of      a      Leg  fracture  or  operation  on  the  leg.     Lateral  view. 

Plaster. — Plaster  ropes  are  applied  to  prevent  the  rotation  of  the 
leg  as  shown  in  figures  77,  78.  The  patient  should  be  disturbed  as 
little  as  possible  for  the  first  five  days,  excepting  for  the  use  of 
the   bed   pan.    He   may    be    allowed    to    have    a    bed    rest   in   two 


52 


TECHNIQUE  OF  OPERATIONS 


weeks  and  to  sit  up  after  the  third  week,  depending  on  the  case. 
Some  cases  are  better  in  bed  for  five  or  six  weeks.  The  leg  should 
be  kept  quiet  for  about  five  weeks  when  the  patient  is  allowed  to  get 
up  and  move  around  with  crutches.  At  the  end  of  the  sixth  week 
he  is  encouraged  to  bear  weight  on  the  leg.  As  soon  as  the  patient 
can  walk  with  the  plaster  easily  it  is  removed  for  a  part  of  each  day 


Fig.  7S. — Plaster  rope  to 
prevent  rotation  of  the  plas- 
ter after  operation.  End 
view. 


and    discarded    as    SOOn    as        Fig.  79.— Dr.  Osgood's  method  of  correcting  knee 
possible,    depending  On   the    Aexion,  removal   of  bone,   A  B,    C,  B'  with  coping 

strength  of  the  leg. 

When  no  operation  has  been  done  on  the  bone,  as  soon  as  the  reaction 
following  the  manipulation  has  subsided,  the  patient  is  allowed  to  sit 
up  and  then  to  walk. 

59.  Dr.  Osgood's  Method  of  Removing  Bone  for  Flexion  Deformity 
at  the  Knee. — Dr.  Osgood  has  suggested  a  method  of  removing  a 
wedge  from  the  femur  by  means  of  a  coping  saw  applied  to  the  femur 
through  two  lateral  incisions.  A  tracing  of  the  x-ray  before  operation 
will  help  the  operator  to  decide  on  the  size  and  shape  of  the  wedge  to  be 
removed  (see  figure  79  A,  B,  C,  B').  A  quadrilateral  piece  of  bone  is  sawed 
out  allowing  correction  of  the  knee  flexion  (see  figure  79  A',  B',  C).  The 
cut  A-B  is  made  three-fourths  of  an  inch  long,  then  B-C  not  through  the 
posterior  shell  of  bone.  The  saw  blade  is  left  at  C.  Another  blade  is 
inserted  at  B'  and  cuts  toward  C.  The  bone  wedge  is  slid  out  and  the 
posterior  shell  at  C  broken  or  bent  as  the  leg  is  straightened.  The  after 
treatment  is  the  same  as  for  osteotomy  above  described. 


CHAPTER  II 


MUSCLE    AND     TENDON     OPERATIONS— MUSCLE    AND    TENDON 
TRANSPLANTATION 

60.  Operation  for  Rupture  of  the  Quadriceps  Extensor.— For  rup- 
ture of  the  quadriceps  a  long  median  incision  is  made.  The  upper  and 
lower  ends  of  the  muscle  and  its  sheath  are  sutured 
with  quilted  silk  sutures  (see  figure  218).  The  silk 
is  pulled  together  approximating  the  edges  of  the 
lower  muscle;  interrupted  chromic  catgut  sutures 
number  00  are  used  for  the  edges  of  the  muscle,  the 
silk  being  used  to  relieve  the  tension.  It  is  impor- 
tant to  suture  the  muscle  sheath  with  interrupted 
catgut  sutures  number  00.  The  fat  is  brought  to- 
gether with  interrupted  chromic  catgut,  the  skin  with 
continuous  chromic  catgut  number  00.  Large  pro- 
tected wads  of  sheet  wadding  are  placed  over  the 
muscle  in  addition  to  the  circular  layers.  The  leg  is 
put  up  in  plaster  of  Paris  with  the  knee  fully  extended. 
The  patient  is  placed  in  bed  with  a  low  bed  rest  and 
the  leg  elevated.  Quiet  in  bed  is  necessary  for  about 
four  weeks;  a  little  more  freedom 
may  be  allowed  in  the  next  two 
weeks.  The  plaster  is  removed 
after  the  sixth  week.  In  patients 
over  thirty,  slight  passive  motions 
of  the  knee  should  be  allowed  daily  Fig. 
after  the  third  week  in  plaster. 

61.  Operation  for  Muscle  Transplantation,  Paraly- 
sis of  the  Anterior  Thigh  Muscles. — When  a  vigorous 
muscle  is  transplanted  strong  muscular  action  can 
usually  be  expected.  In  the  choice  of  muscles  to  be 
transferred  from  the  back  of  the  leg  forward,  the 
sartorius  and  the  inner  hamstrings  are  preferable  to 
the  biceps.  The  biceps,  however,  may  be  trans- 
planted at  the  same  time  with  one  of  the  others. 

Before  transplanting,  any  slight  degree  of  flexion 
or  knock  knee  is  corrected  by  manipulation.  When 
extreme  knock  knee  or  extreme  flexion  is  present  this 
should  be  corrected  at  a  previous  operation.  At  the  time  of  operation 
the  knee  should  hyperextend  slightly  without  the  use  of  force.  When 
this  is  accomplished  the  transplantation  may  be  done. 

53 


80.— Tendon 
carrier. 


Fig.  81. — Sartorius 
incision  anterior; 

hamstring       incision 
posterior. 


54 


TECHNIQUE  OF  OPERATIONS 


OPERATION 


A  rubber  bandage  is  applied  from  the  toes  to  the  groin,  a  tourniquet  is 
applied  high  in  the  groin  with  the  loose  ends  turned  upward  to  allow 
the  skin  to  be  prepared  very  high.  The  patient  is  prepared  with 
scrupulous  care  as  to  aseptic  detail,  the  hip  is  flexed  and  abducted, 


Fig.  82.  —  Exposure 
of   muscles. 


Fig.  S3. — Muscle    dis- 
sected up. 


Fig.  84.  —  Tendon 
carrier,  reaching  pos- 
teriorly for  the  ham- 
string tendon.  The 
line  over  the  patella 
shows  the  incision  here, 
and  over  the  tibia  the 
second  incision  for  in- 
sertion of  the  silk  ten- 
don elongation. 

slightly;  an  incision  is  made 
starting  one  inch  above  and 
half  an  inch  posterior  to 
the  internal  condyle,  the  in- 
cision should  be  carried  ver- 
Fig.  86.  —  Tendon  tically  through  the  skin  and 
carrier    passed    up-  subcutaneous  fat  parallel  to 

ward     through     the     .        .  i         j        i 

subcutaneous  tunnel,  the  femur  and  extend  up- 
ward to  the  middle  and 
upper  thirds  of  the  thigh.  The  muscles  are  examined  to  determine 
their  relative  strength.  For  practical  purposes  a  totally  paralyzed  mus- 
cle will  be  gray,  or  grayish  pink.  A  partially  paralyzed  muscle  is  pink, 
a  strong  muscle  is  red. 

At  the  lower  portion  of  the  wound  the  belly  of  the  semi-membranosis 


Fig.  85.  —  Lateral 
view  of  the  tendon 
carrier  reaching  for 
the  hamstring  tendon. 


MUSCLE  AND  TENDON  OPERATIONS 


55 


is  seen,  then  the  tendon  of  the  semi-membranosis  and  finally  the 
tendon  and  muscle  of  the  semi-tendonosis  overlying  the  semi- 
membranosis.  The  semi-tendonosis  and  the  gracilis  have  long  thin 
tendons,  and  are  chosen  for  transplantation  rather  than  the  semi- 
membranosis. 

When  there  is  a  paralysis  involving  the  muscular  action  of  the  knee 
joint,  it  is  undesirable  to  carry  the  dissection  down  below  the  condyle, 
for  elaborate  dissection  at  the  side  of  the  joint  weakens  it  laterally. 
For  this  reason  the  skin  is  drawn  downward  and  the  tendon  cut  away  as 
low  as  possible  without  being  traced  to  its  insertion  beyond  the  joint 
line. 

The  transplanted  muscle  (see  figure  97)  may  be  passed  through  a  slit 
in  the  quadriceps  tendon  or  muscle  before  being  attached  to  the  quad- 
riceps tendon  and  patella  as  described  above. 

For  the  success  of  the  operation  further  details  are  necessary.  The 
surgeon  should  see  that  the  portion  of  the  silk  hooked  through  the  eye 
of  the  carrier  is  cut  off  later 
in  order  not  to  mutilate  the 
silk  that  is  to  remain  in  the 
leg,  either  by  bending  or 
clamping  it.  Any  injury  to 
the  silk  which  is  to  be  left  in 
the  patient  is  undesirable. 
The  surgeon  should  carefully 
test  the  silk  and  endeavor  to 
break  it  with  his  hands  at 
several  points  before  quilting 
it  through  the  tendon.  The 
stitches  in  the  tendon  should 
be  placed  carefully  and  close 
together  and  not  in  the  same 
line  of  cleavage.  They  should 
number  about  seven  or  eight 
on  each  side  of  the  tendon. 

When  there  is  little  or  no 
tendon,  as  in  the  case  of  the 
sartorius,  "larger  bites" 
through  the  muscle  are  neces- 
sary in  order  not  to  cut  off 
the  circulation  of  the  muscle. 
In  figures  93  and  95  the  tendon  protrudes  through  the  lower  incision 
and  is  quilted  into  the  patella.  The  silk  is  tied  here;  another  incision 
is  made  over  the  outer  side  of  the  upper  end  of  the  tibia  one-half  inch 
internal  to  the  upper  end  of  the  fibula,  curved  and  two  inches  long. 
The  silk  is  quilted  here  into  the  periosteum  and  tied  as  shown  in  fig- 
ures 91  and  92. 


Fig.  87. — A,  Retrac- 
tor preventing  the  in- 
folding of  the  fat  while 
the  muscle  is  drawn 
downward  subcuta- 
neously  to  the  patella. 
B,  Silk  extending  to 
the  tendon  of  the  ham- 
string in  the  tunnel. 


Fig.  88.— Position 
of  insertion  of  an  in- 
ternal hamstring  first 
into  the  patella,  sec- 
ond to  the  outer 
tibia. 


56 


TECHNIQUE  OF  OPERATIONS 


At  the  thigh  in  transplanting  a  posterior  muscle  forward,  the  trans- 
planted muscle  ma}r  be  attached  directly  to  the  quadriceps  tendon  and  to 
the  patella  by  the  silk  extension  from  the  tendon  (see  figure  93).  When 
the  sartorius  is  transplanted  it  is  attached  to  the  quadriceps  and  then 

the  silk  is  carried  over  the 
patella  down  directly  in  a 
straight  line  and  inserted  in 
the  upper  end  of  the  tibia. 
The  muscles  are  transplanted 
in  the  middle  line  above  the 
patella.  Below  the  patella  the 
silk  from  an  inner  hamstring- 
is  carried  to  the  outer  side  of 
the  tibia;  that  from  an  outer 
hamstring  is  carried  to  the 
inner  side  of  the  tibia.  The 
knots  tied  three  times  in  the 
silk  are  cut,  leaving  ends  just 
long  enough  so  that  they  will 
bend  over  and  not  stand  up. 
They  are  also  pressed  firmly 
into  the  periosteum  after  being 
tied  in  order  that  they  will  lie 
The  nee-  as  flat  as  possible.  The  mus- 
dle  must  enter  the  cle  is  dissected  up  to  the  mid- 

gleS011   ^   right   aU"    dle    0f    the    thigh-        A     l0n£[- 

tudinal  incision  is  next  made 
on  the  anterior  and  middle  third  of  the  thigh  parallel  to  the  femur 
down  to  the  quadriceps  muscle.  The  incision  is  retracted,  a  blunt 
dissector  is  used  to  make  a  tunnel  backward  connecting  the  anterior 
with  the  upper  end  of  the  posterior  incisions.  A  long  clamp  or  tendon 
carrier  (see  figure  80)  is  inserted  into  the  tunnel  (see  figures  84,  86), 
anteriorly;  it  grasps  the  tendon  of  the  semi-tendonosis  and  draws  it 
forward  out  through  the  anterior  incision  (see  figures  87,  88).  In  the 
case  of  the  transplantation  of  the  sartorius  or  of  the  gracilis,  this 
tunnel  should  extend  immediately  under  the  fat  and  not  through 
the  paralyzed  muscle  there.  A  towel  is  placed  on  either  side  of 
the  muscle  while  the  heavy  number  eighteen  braided  silk  is  quilted 
up  one  side  of  the  tendon  and  down  the  other  (see  figure  89) . 

The  method  of  inserting  silk  is  extremely  important.  The  tendon 
fibers  are  easily  split  and  tear  readily.  Each  puncture  of  the  needle 
should  be  made  at  right  angles  to  the  fibers  of  the  tendon  as  shown  in 
figure  90. 

Another  incision  is  made  parallel  to  the  femur  starting  one  inch  below 
the  upper  edge  of  the  patella,  extending  upward  two  and  one-half  inches 
directly  over  the  centre  of  the  patella.     The  incision  is  carried  down 


Fig.  89.— Method 
of  quilting  silk  into  a 
tendon. 


MUSCLE  AND  TENDON  OPERATIONS 


57 


through  the  superficial  fascia  and  fat.  A  tendon  carrier  (see  figure  80), 
is  inserted  at  the  patella  incision  making  a  broad  tunnel  in  or  below  the 
subcutaneous  fat  connecting  the  two  anterior  incisions.  The  tendon 
carrier  is  passed  upward  in  the  tunnel  to  the  upper  thigh  incision.  The 
silk  is  passed  through  the  eye  of  the  carrier  and  pulled  through  the  tunnel 
followed  by  the  tendon  and  muscle.  An  assistant  raises  the  lower  end 
of  the  wound  as  shown  in  figure  88  to  prevent  inversion  of  the  fat  at 
this  point  while  dragging  the  muscle  through  the  tunnel.  The  trans- 
planted muscle  is  attached  by  mattrass  sutures  to  the  quadriceps  tendon. 
Both  muscles  are  scarified  before  placing  the  sutures.  The  muscle  is 
also  attached  to  the  quadriceps  muscle  and  tendon  just  above  the  patella. 
This  is  done  with  inter- 
rupted silk  sutures.  The 
quadriceps  may  be  folded 
over  the  transplanted 
muscle  or  slit  to  receive 
it  before  applying  the  in- 
terrupted silk  sutures. 

The  silk  ends  from  the 
transplanted  tendon  are 
threaded  through  peri- 
osteal needles  (see  fig- 
ure 281)  and  inserted  by  Fig 
quilted  sutures  into  the 
patella  (see  figures  91  and 
92) .  The.  silk  is  tied  here 
and  then  passes  subcuta- 
neously  to  the  tibia.  A 
small  curved  incision  is 
made  here  and  the  silk 
quilted  into  the  perios- 
teum over  the  tibia.  The 
deep  tissues  are  brought 
together  with  interrupted  chromic  catgut  sutures  number  00  care- 
fully covering  the  silk  and  the  knot.  The  subcutaneous  fat  is 
brought  together  over  this  with  interrupted  chromic  catgut  sutures 
number  00,  the  skin  with  continuous  chromic  catgut  sutures.  About  five 
or  six  layers  of  gauze  one  and  one-half  inches  wide  are  laid  over  each 
incision  extending  one-half  inches  beyond  at  either  end  of  the  incision. 
Over  this  is  placed  sterile  sheet  wadding.  See  figures  234  to  236. 
See  method  of  applying  dressing  under  transplantation  of  peroneus 
forward,  section  number  147. 

62.  Transplantation  of  Two  Hamstrings  Forward. — When  an  outer 
as  well  as  an  inner  hamstring  is  transplanted  forward  the  process  is  the 
same.  The  two  muscles  are  brought  out  of  the  anterior  incision,  one 
passes  to  it  on  the  outer  side  of  the  leg,  the  other  on  the  inner  side.    They 


91. — Needle  and  insertion 
silk  into  the  periosteum. 


-Quilted    silk    suture 
the  periosteum  and 


Fig.  93. — Insertion 
of  silk  into  patella 
and  into  tibia. 


58 


TECHNIQUE  OF  OPERATIONS 


are  both  passed  down  the  same  tunnel  to  the  patella  and  fastened  to 
the  quadriceps  muscle  or  its  tendon,  both  by  mattrass  sutures  and  then 
stitched  to  the  patella.  The  silk  from  the  inner  muscle  is  cut  from  the 
start  one  inch  or  one  and  one-half  inches  shorter  than  the  silk  from  the 


Fig.   94. — Closing 
anterior  incisions. 


Fig.  95. — Diagram- 
matic representation 
of  the  transplantation 
of  two  hamstrings 
forward  for  paralysis 
of  the  quadriceps. 


Fig.  96. — Anterior 
incisions  closed  after 
transplanting  two 
hamstrings  to  the 
patella  and  tibia  for 
paralysis  of  the  quad- 
riceps. 


outer  muscles.  In  this 
way  it  may  be  dis- 
tinguished after  being 
quilted  into  the  patella  and  tied.  The  quilting  in  the  patella  is  made 
separately  (see  figure  95) ,  for  each  strand.  After  insertion  into  the  patella, 
the  four  strands  are  tied  together  after  being  tied  in  pairs.  They  are  next 
inserted  into  the  periosteum  over  the  tibia,  the  two  strands  of  silk  from 
the  outer  hamstring  to  the  inner  side  of  the  tibia,  and  the  two  strands 
of  silk  from  the  inner  hamstring  are  carried  to  the  outer  side  of  the  tibia. 
The  strands  are  distinguished  by  their  length  as  noted  above.  The 
knots  are  flattened  and  pressed  firmly  into  the  periosteum.  The  silk 
and  knots  are  carefully  covered  with  deep  tissues,  the  subcutaneous 
tissues  are  brought  together  over  this  with  interrupted  chromic  catgut 
sutures  number  00,  the  skin  with  continuous  chromic  catgut  sutures 
number  00.  When  the  incisions  are  closed  they  appear  as  shown  in 
figure  96. 

63.  Operation  for  Transplantation  of  the  Sartorius  Muscle  for  a 
Weak  or  Paralyzed  Quadriceps. — In  a  transplantation  of  the  sar- 
torius, this  muscle  when  transplanted  will  easily  reach  the  patella. 
It  is  usually  sutured  to  the  quadriceps  tendon,  the  two  muscles  scarified 
first.  Silk  is  quilted  into  the  muscle  as  described  for  transplantation  of 
the  semi-tendinosus  or  the  peroneus.     The  silk  is  carried  down  and  in- 


MUSCLE  AND  TENDON  OPERATIONS 


59 


serted  into  the  patella  and  then  into  the  tibia  in  the  median  line,  otherwise 
the  operation  is  the  same  as  in  transplantation  of  the  semi-tendinosus 
forward.  The  sartorius  is 
an  easy  muscle  to  trans- 
plant and  when  strong  is 
always  successful  in  its 
new  position. 

64.  Transplantation  of 
the  Tensor  Fascia  Femo- 
ris,  to  a  Weak  or  Para- 
lyzed Quadriceps. — The 
patient  lies  on  his  back, 
the  operator  stands  on 
the  side  of  the  leg  to  be 
operated  upon. 

An  incision  is  made  to 
the  patella  starting  two 
inches  below  the  anterior 
superior  spine.  The  ten- 
sor fascia  femoris  muscle 
is   exposed   and    a   broad 


Fig.  98.— The  para- 
lyzed quadriceps  is 
folded  in  part  over  the 
transplanted  muscle 
which  is  attached  to 
the  patella  and  again 
to  the  tibia. 


Fig.  97. — Passing  the 
transplanted  muscle 
through    the  quadriceps 

strip  of  fascia  traced  down  and  then  attaching  the 

to    two    inches    above    the    silk     extension     to     the 

patella.    This  is  cut  away  pateUa  and  tibia' 

below,    dissected    up, 

quilted  up  one  side  and  down  the  other  with  silk,  the  fascia  and  muscle 

transferred  inward  entering  a  slit  in  the  quadriceps  tendon  and  being 

attached  by  quilted  sutures  to  the  quadriceps  tendon  and  patella.    The 

rest  of  the  operation  and  after  treatment  differ  in  no  way  from  that 

used  in  the  transplantation  of  the  semi-tendinosus.    See  section  61. 

65.  Transplantation  of  the  External  Hamstrings  Forward,  for  a 
Weak  or  Paralyzed  Quadriceps. — In  transplanting  the  external  ham- 
string, the  biceps  femorus,  the  short  and  long  heads  come  together  into 
one  tendon.  The  incision  for  transplanting  this  tendon  should  be  one 
or  two  inches  from  the  median  line.  In  transplanting  this  muscle  for- 
ward it  is  better  that  the  tunnel  should  pass  through  to  the  inner  side 
of  the  vastus  externus,  for  it  is  difficult  to  make  the  muscle  reach. 
The  tendon  should  be  cut  very  low  for  the  same  reason.  The  pro- 
cedure otherwise  is  the  same  as  for  transplantation  of  the  inner  ham- 
string. 

66.  Technique  of  Muscle  Transplantation.— In  transplanting  mus- 
cles or  tendons  from  their  position  to  take  up  the  work  of  other  muscles, 
it  is  important  to  weigh  the  strength  of  the  paralyzed  group,  and  deter- 
mine the  strength  of  the  muscles  to  be  transplanted  and  the  strength 
of  the  joint  after  removing  this  good  muscle.  If  the  joint  stability  is  in 
any  great  degree  affected  by  the  transfer,  this  must  in  some  way  be 


60 


TECHNIQUE  OF  OPERATIONS 


compensated  for  and  if  it  cannot  be,  the  operator  should  consider  the 
value  of  the  transplantation  with  these  facts  in  mind. 

At  the  time  of  operation,  a  red  muscle  will  be  a  good  one  to  transfer, 
a  pink  muscle  may  be  of  help  in  its  new  position  but  if  it  is  a  pinkish 
gray  or  fatty  it  will  be  useless  when  transplanted.  The  muscle  to  be 
transferred  should  be  dissected  up  for  at  least  one-half  of  its  length  from 
its  insertion,  carried  forward  or  backward  as  the  case  may  be,  and  then 
placed  in  a  tunnel  in  a  direct  line  for  the  desired  new  pull.  The  silk 
quilted  into  the  tendon  should  extend  some  distance  up  the  tendon  in 
order  not  to  be  easily  pulled  out.  The  silk  should  be  heavy  number 
sixteen  or  number  eighteen,  braided.  It  should  be  tested  to  see  if  it  will 
break  before  inserting  it  in  the  tendon.  The  silk  can  be  made  to  reach 
any  distance.  In  the  process  of  repair  it  is  covered  completely  by  fibrous 
tissue  which  will  strengthen  it.  The  insertion  of  the  silk  into  the  perios- 
teum should  be  three  or  four  quilted  sutures  for  each  strand  (see  figure  91, 
92) ,  and  then  the  ends  are  pulled  tight  one  at  a  time,  taking  up  the  slack 
in  the  muscle  and  then  tied  three  times,  the  end  cut  so  that  it  will  bend 
over.  The  knot  is  pressed  into  the  underlying  tissue  using  the  handle 
of  a  pair  of  dressing  forceps.  The  operator  should  assure  himself  that 
the  transplanted  muscle  is  pulled  well  down  into  its  new  position  and  is 
not  caught  by  any  constriction  in  the  canal  in  which  it  has  been  placed. 
The  insertion  of  the  silk  should  be  under  a  curved  flap,  the  base  of  which 
overlies  the  knot.  The  silk  should  be  covered  by  deep  fascia  or  muscle 
when  possible  beside  the  skin  and  fat.  No  pressure  should  be  allowed 
over  the  transplanted  muscles  or  the  incision.  The  dressings  or  plasters 
should  be  well  padded  for  this  purpose. 

67.  Muscle  Transplantation  for  Paralysis  of  the  Anterior  Thigh 
Muscles. — One  or  more  posterior  thigh  muscles  may  be  transplanted 

forward  to  re-enforce  a 
very  weak  quadriceps  or 
to  replace  a  paralyzed 
one.  It  must  be  borne  in 
mind  that  the  object  of 
the  transplantation  is  pri- 
marily to  give  stability  to 
the  knee.  A  very  weak 
or  paralyzed  quadriceps 
is  a  constant  menace  to 
the  patient.  In  walking 
he  cannot  lock  the  knee 
and  be  sure  when  trans- 
ferring the  weight  from  the  good  leg  to  the  affected  leg  that  it  may  not 
give  way  under  him.  In  walking  he  instinctively  places  the  hand  on  the 
thigh  to  prevent  the  flexion  of  the  knee  as  the  weight  is  being  trans- 
ferred to  that  leg. 

Stability  in  standing,  the  motions  of  stepping  up  and  of  stepping 


Fig. 


99. — Roll  of  sheet  wadding  applied   after  tendon 
transplantation  before  applying  the  plaster. 


MUSCLE  AND  TENDON  OPERATIONS 


61 


Fig 


-Sheet    wadding    being    applied 
sheet  wadding. 


of 


forward,  as  well  as  the  extension  of  the  knee  are  largely  dependent  on 
the  quadriceps.  When  this  muscle  is  absent,  or  deficient,  one  or  more 
of  the  posterior  thigh  muscles  may  be  transferred  forward.  While  in 
transplantation  none  but 
good  strong  muscles 
should  be  used  as  a  rule, 
in  the  case  of  the  knee  a 
weak  muscle,  when  there 
are  no  others,  will  help 
give  stability  when  trans- 
planted even  if  it  is  not 
strong  enough  to  extend 
the  knee  with  force. 
When  such  a  transplant- 
ation is  performed  the  patient  or  his  relatives  should  realize  the  pur- 
pose of  the  operation  in  order  not  to  expect  more  than  the  increased 

stability  of  the  knee  where 
such  a  weak  muscle  is  used. 
68.  Plaster  of  Paris 
Bandage  Following  Trans- 
plantation in  the  Thigh. — 
A  plaster  of  Paris  bandage 
is  applied  from  the  toes  to 
the  groin  and  split  on  ei- 
ther side  when  dry  enough. 

Fig.  101.— Sheet  wadding  rollers  applied  for  plaster.  The    knee   is   held    slightly 

After  a  tendon  or  muscle  transplantation  the  plaster  hyperextended.      No    pres- 

should  extend  as  high  as  possible  on  the  leg  and  include  &me     h      M  bg  allowed  on 
the  foot. 

the  knee  cap  or  on  the 
transplanted  muscles.  To  avoid  this  a  great  deal  of  folded  sheet  wad- 
ding is  laid  over  the  anterior  part  of  the  thigh  and  patella  before  ap- 
plying the  circular  sheet 
wadding  (see  figures  99, 
100,  101).  The  foot  of 
the  plaster  should  be  ele- 
vated and  always  loosened 
but  strapped  at  either 
side.  While  there  is  usu- 
ally much  swelling  there 
will  be  comparatively  less 
if  the  operator  avoids 
roughness  in  handling  the 

tissues. 

After  Treatment 

The  patient  is  kept  on  his  back  for  a  week  and  then  raised  forty-five 
degrees  on  a  bed  rest  for  part  of  the  time.    When  the  swelling  has  sub- 


Fig.  102. — A  plaster  whether  extending  to  the  groin 
or  the  knee  may  be  split  at  the  sides  so  that  it  can  be 
loosened  or  taken  off. 


62  TECHNIQUE  OF  OPERATIONS 

sided  he  may  sit  up  in  bed.  He  should  not  move  much  for  two  weeks; 
after  that  he  may  change  his  position  frequently  in  bed.  At  the  end  of 
six  weeks  he  is  allowed  to  get  out  of  bed  in  a  chair  or  go-cart.  At  the 
end  of  eight  weeks  the  plaster  is  changed  and  the  patient  walks  with 
crutches  on  the  other  leg,  gradually  using  the  leg  operated  on.  A  caliper 
splint  is  used  after  the  tenth  week,  replaced  by  the  plaster  at  night. 
Muscle  training  and  exercises  are  kept  up  for  a  year  and  a  half  at  least. 
The  knee  is  allowed  to  bend  fifteen  degrees  at  first  but  not  more  than 
forty-five  degrees  for  a  year;  after  that  flexion  is  allowed  just  short  of  a 
right  angle.    Early  stretching  beyond  a  right  angle  weakens  the  muscle. 

69.  Myotomy  of  the  Adductors  and  Hamstring  Muscles.  For  Con- 
tracted Muscles. — When  the  adductor  muscles  and  hamstrings  are 
contracted  and  will  not  yield  easily  to  gradual  or  forcible  stretching 
under  anaesthesia,  they  are  better  lengthened  in  the  tendinous  portion 
as  described  under  tendon  lengthening.  The  contraction  may  be  due 
to  disease,  to  injuries  or  to  habit  of  position  or  abnormal  tensions,  and 
in  spastic  paralysis  it  is  often  necessary  to  throw  the  contracted  spastic 
muscle  temporarily  out  of  commission.  In  this  class  of  spastic  cases  a 
simple  myotomy  may  be  done.  If  it  is  necessary  to  put  the  muscle  ab- 
solutely out  of  commission,  in  order  that  locomotion  may  be  possible, 
either  a  transplantation  of  the  muscle  is  made  to  where  it  will  be  more 
useful  or  a  section  from  the  muscle  is  removed. 

70.  Operation  for  Tenotomy  of  the  Hamstrings  or  Tendon  Length- 
ening.— This  operation  should  never  be  done  subcutaneously.  A 
very  small  incision  should  be  made  over  the  outer  and  another  over  the 
inner  side  of  the  popliteal  space.  Each  tendon  is  lifted  out  on  a  blunt 
dissector  or  grooved  director  and  tenotomized,  care  being  taken  not 
to  cut  the  nerves  which  are  large.  The  surgeon  may  feel  for  each  tendon, 
lift  it  and  cut  it  in  turn.  The  actual  cutting  of  the  tendon  should  be 
according  to  the  rules  laid  down  elsewhere  in  these  pages  under  tenotomy 
and  tendon  lengthening  (see  section  127). 

The  after  treatment  is  the  same  as  that  laid  down  for  myotomy  of  the 
hamstrings.     See  section  82. 

Sometimes  a  hasty  operation  is  all  that  the  patient  will  stand  if  he 
is  weak  or  is  bedridden.  In  this  type  of  case  the  legs  should  be  made 
straight  and  the  muscles  stretched  enough  at  each  joint  simply  to  make 
standing  and  locomotion  possible.  The  foot  should  never  be  forgotten. 
A  good  hip  or  patched  up  knee  is  not  very  useful  if  the  foot  cannot  be 
used  for  standing.    In  a  few  cases  one  leg  must  be  done  at  a  time. 

In  cases  for  myotomy  when  the  patient  is  not  strong  enough  to  have 
one  leg  made  good  for  weight  bearing  it  is  better  to  wait  and  strengthen 
the  general  condition  by  rest,  exercise,  hygiene,  etc. 

71.  Myotomy  in  Spastic  Paralysis. — A  myotomy  of  the  adductor  or 
inner  and  outer  hamstrings  or  of  the  peronei  or  the  muscles  of  the  leg 
or  arm  is  performed  in  a  similar  way  to  that  described  under  myotomy 
for  the  inner  hamstrings.    The  surgeon  should  remember  that  tenotomy 


MUSCLE  AND  TENDON  OPERATIONS  63 

or  tendon  lengthening  when  applicable  is  preferable  to  myotomy  except- 
ing in  spastic  paralysis  and  other  paralysis  when  it  is  necessary  to  throw 
out  of  action  muscles  that  are  a  hindrance  to  locomotion. 

Spastic  cases  not  able  to  walk  on  account  of  the  adduction  of  the  thigh 
and  flexion  of  the  knee  are  greatly  relieved  by  this  operation.  They 
may  walk  at  first  with  difficulty  and  with  apparatus  only,  but  later  will 
improve  a  great  deal. 

72.  Operation  for  Myotomy  of  the  Internal  Hamstring. — A  vertical 
incision  four  inches  long  is  made  on  the  inner  and  posterior  aspect  of  the 
thigh  at  the  junction  of  the  middle  and  lower  third  down  to  the  muscle 
layer.  The  semi-tendinosis  is  posterior  and  may  be  recognized  by  its 
long  tendon,  the  semi-membranosis  by  its  large  bulk  and  low  muscle 
fibers,  the  gracilis  is  forward  of  this  with  a  long  tendinous  portion  and 
the  sartorius  is  a  flat  muscle,  narrow  and  long  with  parallel  edges;  it 
has  almost  no  tendon.  The  muscles  selected  for  myotomy  are  taken  in 
turn,  the  fibers  are  lifted  on  a  director  and  cut  a  few  at  a  time.  This  is 
repeated  until  the  muscle  is  completely  cut  across.  If  the  muscle  is  to  be 
completely  thrown  out  of  commission,  as  in  certain  cross  legged  spastic 
conditions,  a  section  one  or  two  inches  is  cut  out  of  each  muscle  as  fol- 
lows. 

73.  Operation  for  Removing  a  Section  from  a  Muscle. — In  removing 
a  section  the  muscle  is  cut  twice.  For  the  upper  cut  the  muscle  fibers  are 
lifted  on  a  director  a  few  at  a  time  as  described  above  for  a  simple  myot- 
omy. A  second  cut  is  made  one  or  two  inches  below.  The  lower  cut  is 
made  at  once  with  scissors.  When  the  muscle  is  very  vascular  it  is 
transfixed  in  one  or  two  places  with  a  stab  needle,  double  ligatures  passed 
through  interlocked,  and  tied  as  in  tying  pedicles.  The  muscle  is  then 
cut.  A  second  cut  is  made  one  and  one-half  inches  lower,  the  muscle 
tied  off  in  the  same  way.  The  tying  of  a  muscle  before  cutting  is  rarely 
necessary.  The  ends  thus  separated  and  tied  are  not  apt  to  reunite. 
The  subcutaneous  fat  is  sutured  with  interrupted  chromic  catgut  sutures 
number  00,  the  skin  with  continuous  chromic  catgut  sutures  number  00. 
No  hemorrhage  is  likely  even  when  large  vascular  muscles  are  cut  across. 
The  operator  may  prefer  to  turn  back  and  suture  the  ends  of  the  muscle 
myotomized.     This  will  effectually  prevent  reunion. 

At  the  time  of  operating  on  the  muscles,  the  joints  should  be  limbered 
up  allowing  normal  motion  at  the  hip;  the  knees  hyperextended  slightly 
and  flexed  to  a  right  angle.  The  ankle  motion  should  also  be  investigated 
and  made  suitable  for  weight  bearing  and  walking.  In  other  words,  the 
deformities  and  limitations  of  motion  should  be  overcome. 

After  Treatment 

The  joint  about  which  the  myotomy  is  done  should  be  immobilized 
by  a  plaster  of  Paris  with  the  muscle  held  stretched  out  for  eight  weeks. 
When  the  plasters  are  removed,  caliper  splints  should  be  used  to  keep  the 


64  TECHNIQUE  OF  OPERATIONS 

knees  slightly  hyperextended.  The  length  of  time  necessary  for  the 
caliper  splints  depends  on  the  tendency  of  the  knee  to  contract. 
The  splints  are  omitted  a  little  and  the  time  increased  accordingly 
until  they  are  worn  each  day  one  or  two  hours  only.  This  is  kept  up 
for  a  year.  The  abduction  is  maintained  part  of  each  day  by  a  wooden 
spreader  between  the  braces.  Any  tendency  to  recontraction  is  followed 
by  more  vigorous  use  of  the  splints.  The  legs  should  be  watched  so  that 
motion  in  abduction  is  easy  and  hyperextension  of  the  knees  possible 
without  using  force. 

74.  Operation  for  Tenotomy  of  the  Adductor  Magnus. — This  tendon 
is  easily  felt  just  above  the  internal  condyle  of  the  femur.  An  incision 
is  made  one-half  inch  or  one  inch  long  just  enough  for  the  finger  to 
feel  the  tendon  (see  figure  48),  it  is  hooked  up  on  a  blunt  dissector  and 
tenotomized;  one  suture  closes  this  incision.  This  operation  is  especially 
useful  for  contractures  of  the  unopposed  adductor;  it  is  also  useful  in 
helping  relax  a  difficult  and  shortened  dislocated  femur,  or  before  per- 
forming an  arthrodesis  at  the  hip  or  to  help  overcome  adduction  for  any 
reason. 


CHAPTER  III 

OPERATION  IN  CASES  OF  PARTIAL  AND  TOTAL  PARALYSIS 

75.  Arthrodesis  at  the  Knee  in  Paralytic  Conditions  (See  also 
Chapter  II). — In  infantile  paralysis  and  other  paralytic  conditions 
elaborate  operations  and  heavy  apparatus  are  to  be  avoided  whenever 
possible.  When  there  is  a  complete  paralysis  of  the  muscles  about  both 
knee  joints,  especially  when  the  hip  muscles  are  good,  it  is  often  de- 
sirable to  relieve  the  strain  of  carrying  apparatus  by  stiffening  one 
knee. 

The  usual  semilunar  incision  is  to  be  avoided  as  should  most  of  the 
cross  incisions  in  paralytic  conditions.  The  circulation  and  repair  is 
naturally  poor.  In  order  to  interfere  as  little  as  possible  with  the  cir- 
culation, longitudinal  incisions  can  be  made  on  either  side  of  the  patella 
four  or  five  inches  long  in  order  to  allow  easy  retraction  of  the  tissues. 
Very  much  less  disturbance  of  the  circulation  is  obtained  by  this  method 
than  by  the  usual  semilunar  incision.  A  bayonet  incision  is  often  pre- 
ferred in  these  cases. 

OPERATION 

A  rubber  bandage  is  applied  from  the  toes  to  the  groin  and  a  tourniquet 
is  applied  here,  the  leg  having  been  carefully  prepared.  Any  deformity, 
such  as  flexion  or  bow  leg  or  knock  knee  should  be  corrected.  A  bayonet 
incision  or  two  parallel  incisions  are  made  four  inches  long,  one,  one  inch 
from  the  outer  border,  and  the  other,  one  inch  from  the  inner  border  of 
the  patella  (see  figures  119  and  120).  They  should  extend  from  the  cross 
incision  over  the  patella  upward  and  downward  two  inches.  The 
incisions  are  carried  down  to  the  bone,  the  soft  tissues  retracted  exposing 
the  knee  joint  (see  section  92).  The  lateral  ligaments  are  incised  or 
detached  subperiosteal^  and  an  osteotome  is  used  to  remove  the  articu- 
lar surface  of  the  tibia  or  a  saw  when  a  large  slice  of  bone  is  to  be 
removed.  The  lower  end  of  the  femur  is  also  shaved  off  with  an 
osteotome,  the  two  bony  surfaces  brought  into  firm  apposition  and 
sutured  laterally  and  anteriorly  by  means  of  heavy  silk  or  silver 
wire.  Bone  plates  may  be  used,  vanadium  steel  plates  are  easily 
bent  and  the  surface  of  the  bone  should  be  cut  with  an  osteotome  to 
receive  them  so  that  their  surface  will  lie  flat.  The  under  side  of  the 
patella  may  be  cut  away  with  an  osteotome  and  mortised  into  a 
groove  cut  in  the  anterior  surface  of  the  tibia  and  femur,  the  patella 
being  pulled  down  and  firmly  anchored  to  those  bones  by  means 
of  silk  (see  figures  103,  104,  105).    This  latter  procedure  is  unnecessary 

65 


66 


TECHNIQUE  OF  OPERATIONS 


when  a  bony  arthrodesis  has  been  done.  It  may  be  used  as  a  substitute 
for  the  bone  operation.  A  bone  graft  from  the  tibia  will  help  lock  the 
bones  together.  The  graft  is  taken  from  the  same  leg,  as  recommended 
by  Albee.    In  cases  other  than  infantile  paralysis  an  arthrodesis  is  done 


Fig.  103. — After  excision  or  arthro- 
desis, silk  ligaments  applied  to  the 
patella,  step  I. 


Fig.  104. — After  excision  for 
arthrodesis,  silk  ligaments  ap- 
plied to  the  patella,  suture  of 
patella  tendon,  step  II. 


like  an  excision  through  an  anterior  semilunar  incision.    See  elsewhere  in 
these  pages,  excision  of  the  knee.     See  section  97. 

76.  Operation  for  Flail  Condition  of  the  Knee. — When  there  is  a 
paralysis  of  the  muscles  of  the  leg  in  extensive  paralytic  conditions  not 
only  is  the  knee  flail  because  of  the  lack  of  power  in  the  flexors  and  ex- 
tensors but  the  ligaments 
lack  tone  and  are  stretched 
out  so  that  there  is  a  lateral 
flail  condition  as  well  as  an 
antero-posterior.  For  the 
slight  conditions,  the  Bar- 
low silk  ligaments  are  suffi- 
cient. For  the  very  extreme 
cases  an  arthrodesis  at  the 
knee  and  a  bone  graft  in 
addition  is  indicated.  This 
eliminates  elaborate  appar- 
atus and  allows  the  use  of 
the  leg  without  cumbersome 
braces.  When  the  hip  mus- 
cles are  good  the  result  is 
especially  gratifying.  Loco- 
motion becomes  easy,  the  weight  of  apparatus  is  eliminated  and  the 
circulation  in  the  leg  becomes  greatly  improved. 


Fig.  105. — After  exci- 
sion for  arthrodesis,  silk 
ligaments  applied  to  the 
patella,  wound  closed, 
step  III. 


Fig.  106. — View  of 
popliteal  space  inci- 
sions for  silk  liga- 
ments. 


OPERATION  IN  CASES  OF  PARALYSIS 


67 


77.  Operation  for  Inserting  Bartow  Silk  Ligaments  at  the  Knee  in 
Paralytic  Conditions. — The  Bartow  method  of  inserting  silk  ligament 
has  proved  of  service 
especially  at  the  knee 
and  shoulder.  The  lig- 
aments are  introduced 
intra-articularly  going 
through  the  bone  be- 
low, the  joint  and  the 
bone  above,  then  down 
in  front  of  the  bone, 
preferably  through  the 
capsule  of  the  joint 
and  in  front  of  the 
bone  below  and  tied. 
They  may  be  inserted 
subcutaneously  with- 
out incision,  at  the 
shoulder  and  at  the 
front  of  the  knee.  At 
the  back  of  the  knee, 
however,  it  is  better  to 
make  a  small  incision 
(see  figures  108,  109 
and  110)  for  the  en- 
trance and  exit  of  the 
special  curved  drill. 
This  instrument  con- 
sists of  a  handle  (see  figure  109),  and  a  set  of  drills  which  are  long  and 
have  different  curves,  the  operator  selecting  the  curve  most  adapted  to 
the  joint  which  he  is  operating  upon. 

When  there  is  no  power  of  extension  of  the  knee  or  when  this  power  is 


Fig.  107. — View  of  popli- 
teal space,  insertion  of  a  pos- 
terior inner  silk  ligament. 
1.  Semi-tendonosis.  2.  Semi- 
mem  branosis.  3.  Gracilis.  4. 
Inner  head  of  gastrocnemius. 
5.  Femur.    6.  Tibia. 


Fig.  108.— View  of 
popliteal  space,  inser- 
tion of  a  posterior  ex- 
ternal silk  ligament. 
1.  Biceps.  2.  Gastroc- 
nemius. 3.  Femur.  4. 
Tibia. 


Fig.  109. — Bartow  drill.  The  handle  allows  the  drill  to  protrude  slightly 
as  it  enters  the  bone.  The  drill  handle  slides  back  on  the  drill  and  is  held 
by  a  thumb  screw.  The  drills  are  made  with  different  curves  all  fitting  into 
the  drill  handle. 

so  slight  that  it  is  impossible  for  the  patient  to  use  the  knee  satisfactorily 
without  a  splint,  the  Bartow  silk  ligament  may  be  used  instead  of  a  brace. 


68 


TECHNIQUE  OF  OPERATIONS 


They  will  hold  the  knee  firmly,  sometimes  allowing  a  little  motion  but 
not  enough  to  give  way  when  weight  is  applied  to  the  leg.  When  there 
is  a  flail  condition  of  the  knee  four  or  six  ligaments  may  be  applied,  two 
anteriorly  and  two  posteriorly.  When  the  knee  tends  to  hyperextend 
backward  and  there  are  muscles  anteriorly,  two  posterior  ligaments 
may  be  used.  They  will,  however,  limit  the  motion  of  the  knee  some- 
what. Where  the  muscles  are  weak  this  limitation  is  not  undesirable. 
In  selected  cases  the  Bartow  silk  ligaments  are  most  useful  at  the  knee. 


OPERATION 


The  leg  having  been  cleaned,  prepared  and  protected  as  for  any  joint 
operation,  a  Bartow  drill  (see  figure  109),  is  entered  one  inch  or  one  and 


Fig.  110. — Bartow  silk 
ligament  at  the  knee,  in- 
sertion of  the  drill.  The 
eye  of  the  drill  is  threaded 
with  silk. 


Fig.  111. — Bartow  silk 
ligament  at  the  knee,  pos- 
terior ligament  in  place. 


Fig.  112. — Bartow  silk  liga- 
ment at  the  knee,  insertion  of 
drill. 


one-half  inches  from  the  middle  of  the  tubercle  of  the  tibia.  The  drill 
is  pushed  through  the  skin  and  bone  at  this  point  extending  through  the 
tuberosity  of  the  tibia  and  upward  (see  figure  113),  emerging  at  the  top 
of  the  tibia  into  the  joint;  it  next  enters  the  lower  surface  of  the  femur 
and  comes  out  anteriorly  to  the  side  of  the  patella.  A  piece  of  fine  tough 
braided  silk  number  10  or  linen  thread  is  cut  ten  inches  long,  its  two 
ends  are  threaded  through  the  drill,  the  drill  is  withdrawn.  This  fine 
silk  is  used  as  a  leader  to  draw  the  heavy  silk  through  the  bone.  A  num- 
ber 18  silk  is  threaded  through  the  loop  of  the  fine  silk  and  drawn  through 
the  bone  double.  The  drill  is  next  introduced  subcutaneously  at  the 
lower  incision  and  made  to  protrude  from  the  upper  incision.  The  silk 
is  threaded  through  it  and  brought  down  subcutaneously  out  through 
the  lower  skin  incision  (see  figure  113).  We  now  have  the  silk  extending 
through  the  tuberosity  of  the  tibia,  emerging  at  the  top  of  the  tibia  into 
the  joint,  into  the  lower  end  of  the  femur  and  out  through  the  anterior 


OPERATION  IN  CASES  OF  PARALYSIS 


69 


surface  of  the  femur  and  down  subcutaneously  in  front  of  both  bones 
(figure  113),  to  be  tied  in  front  of  the  tibia.  In  the  same  way  a  second 
parallel  ligament  is  placed.  There  is  then  one  to  the  outer  and  the  other 
to  the  inner  side  of  the  patella.  Where  the  knee  joint  is  particularly 
relaxed,  additional  ligaments  may  be  placed  at  the  inner  side  and  at  the 
outer  side  of  the  knee  joint  and  posteriorly  (see  figures  110  and  111). 
The  knee  is  slightly  hyperextended  before  tying  the  ligaments;  they 
should  be  tied  three  times,  double  strands  having  been  used  for  each 
ligament.  The  ends  are  cut  about  one-sixteenth  of  an  inch  long,  the 
skin  is  lifted  by  means  of  forceps  allowing  the  knot  to  slip  below  the  skin 
and  below  the  fat.  The  knot  is  compressed  by  means  of  a  blunt  in- 
strument, in  order  that  it  may  not  be  too  prominent 
under  the  skin.  No  sutures  are  necessary.  Any 
other  operation  to  be  done  on  the  hip  or  leg  should 
be  completed  before  tying  the  ligaments  at  the 
knee.  No  strain  should  be  allowed  on  the  new  liga- 
ments after  they  are  tied.  When  there  is  a  ten- 
dency to  hyperextension  at  the  knee  or  when  the 
knee  joint  is  extensively  relaxed,  posterior  liga- 
ments are  applied  in  a  similar  way  but  at  the 
posterior  part  of  the  tibia,  and  at  the  posterior 
part  of  the  femur,  a  small  incision  above  and  a 
small  incision  below  is  made  through  which  the 
drill  is  applied  to  the  bone. 

Any  lateral  deformity  or  any  permanent  flexion 
should  be  corrected  before  inserting  the  liga- 
ments. 

An  arthrodesis  is  preferable  in  very'  heavy 
patients  with  extensive  paralysis  or  in  young  patients  with  an  extensive 
paralysis  as  the  patient  may  be  heavier  later  on.  But  when  there  is 
some  joint  stability  or  a  little  muscular  power  these  ligaments  are 
satisfactory. 

The  after  treatment  consists  of  protection  in  plaster  of  Paris  for  eight 
weeks  or  longer;  then  a  caliper  splint  is  used  until  the  patient  is  able  to 
walk  with  confidence.  The  caliper  then  is  at  first  worn  loose,  a  little 
each  day,  then  omitted  a  little  each  day  until  not  needed. 


Fig.  113.— Bartow  silk 
ligament  at  the  knee,  an- 
terior and  posterior  liga- 
ments in  place. 


CHAPTER  IV 


INCISION,    PUNCTURES   AND    ARTHROTOMY 


78.  Operation  for  Displaced  Semilunar  Cartilage. — When  operation 
is  indicated  for  slight  or  considerable  displacement  of  the  semilunar  carti- 
lage, one  of  several  incisions  may  be  used.     An  esmark  is  applied  and  a 
tourniquet.     The  leg  should  be  prepared  and  the  field  of  operation  well 
protected,  the  knee  flexed  at  right  angle  preferably 
off  of  the  end  of  the  operating  table  as  suggested  by 
Mr.  Jones.    The  protecting  sterile  sheets  should  in- 
clude the  foot  and  leg  to  above  the  calf.    The  upper 
/  ^- — -  sheets  should  extend  down  to  a  point  two  inches 

above  the  patella.    The  flexed  knee  hangs  off  of  the 
operating  table  resting  on    a    double   sterile  sheet 
which  covers  the  other  leg.    After  the  skin  incision, 
towels  may  be  clamped  to  the  edges  of  the  retracted 
skin  and  a  fresh  knife  and  instruments  used  to  com- 
plete the  operation.    A  crecenteric  incision  (see  fig- 
ures 114, 115)  is  made  directly  downward  one-half  inch 
for  semilunar  carti-  to  the  inner  side  of  the  patella  down  to  the  tibia, 
lage,  made  with  knee  then  curving  at  right  angles  along  the  upper  edge  of 
d-  the  tibia  for  two  and  one-half  inches.    The  tissues  are 

dissected  up  in  one  layer  down  to  the  tough  fibrinous  capsule  for  the 
full  line  of  the  incision.  The  flap  is  retracted  inward  and  the  fibers  of 
the  capsule  incised  leaving  the  synovial  membrane 
unopened.  Any  bleeding  points  should  be  checked  at 
this  point.  The  synovial  membrane  is  held  up  with 
a  pair  of  forceps  and  nicked  with  a  pair  of  scissors 
and  then  opened  just  above  and  parallel  to  the  line 
of  the  tibia.  This  gives  ready  access  to  the  semilunar 
cartilage.  The  inner  semilunar  cartilage  is  a  little 
thicker  through' than  the  external,  it  is  elliptical  in 
shape,  while  the  external  semilunar  cartilage  is  not  as 
thick  through,  and  is  circular  and  longer.  If  it  is 
loose  or  turned  up  it  should  be  lifted  with  a  pair  of 
forceps  and  a  pair  of  blunt  curved  scissors  used  to  dis- 
sect it  from  its  underlying  attachment  as  far  posterior 
as  possible,  but  in  no  case  should  the  lateral  ligament  of  the  joints  be 
cut  to  make  the  removal  more  complete.  The  joint  should  in  no  other 
way  be  interfered  with.  All  but  the  most  posterior  portion  of  the  carti- 
lage is  removed.  Any  bleeding  in  the  joint  is  checked  by  hot  saline  solu- 
tion on  cotton  pledgets;  fine  catgut  or  silk  is  used  to  close  the  synovial 

70 


Fig.  115.  —  Anterior 
view  of  semilunar 
cartilage  incision. 


INCISION,  PUNCTURES  AND  ARTHROTOMY  71 

membrane.  The  joint  capsule  is  brought  together  with  interrupted 
chromic  catgut  sutures  number  00,  the  skin,  fat  and  fascia  with  inter- 
rupted chromic  catgut  number  00.  A  splint  or  plaster  may  be  used  for 
three  days.    After  that  no  apparatus  should  be  used. 

Small  degrees  of  motion  are  encouraged  after  the  fifth  or  seventh  day. 
The  patient  is  up  on  crutches  at  the  end  of  two  weeks,  and  weight  bearing 
allowed  at  the  end  of  the  fourth  week.  The  surgeon  should  be  guided 
by  the  amount  of  swelling.  When  it  is  possible  to  handle  the  tissues  care- 
fully at  the  time  of  operation  surprisingly  little  reaction  occurs  from  the 
operation. 

79.  Operation  for  Torn  Crucial  Ligaments  at  the  Knee. — Injury 
and  repair  of  crucial  ligaments.  The  damage  is  readily  detected  when 
operating  for  deranged  condition  of  the  joint  and  any  tear  repaired  with 
quilted  silk  sutures.  The  motion  of  the  crucial  is  then  tested  with  the 
knee  flexed  and  extended.     See  figure  117. 

The  anterior  crucial  ligament  extends  anteriorly  from  the  inner  to 
the  outer  side  obliquely.  The  posterior  crucial  ligament  extends  from 
the  outer  side  to  the  inner  nearly  vertically. 

The  patient  lies  on  his  back,  the  operator  stands  on  the  side  of  the 
leg  to  be  operated  on.  An  esmark  rubber  bandage  and  tourniquet  is 
applied,  the  skin  having  been  prepared  with  scrupulous  care  as  to 
aseptic  detail,  sterile  sheets  cover  the  upper  third  of  the  thigh  and 
lower  leg  and  foot  from  two  inches  below  the  tibial  tubercle. 

An  incision  is  made  in  the  median  line  starting  four  inches  above  the 
patella  and  extending  vertically  downward  in  the  median  line  to  just 
below  the  adductor  tubercle.  The  dissection  is  carried  down  in  one  layer 
through  the  skin  and  fat,  the  edges  of  which  are  dissected  up  and  re- 
tracted. At  this  point  the  operator  if  he  wishes  may  additionally  pro- 
tect the  incision  by  clamping  sterile  towels  to  the  retracted  edges  of  the 
skin  and  fat  and  use  fresh  instruments  for  completing  the  operation. 

The  incision  is  made  to  the  bone  over  the  patella;  the  muscle  and  ten- 
don adjoining  are  separated  in  the  median  line  above  and  below.  A  saw 
is  used  to  separate  the  patella.  When  it  is  cut  two-thirds  through,  the 
knee  is  then  flexed  and  a  chisel  or  osteotome  is  used  to  complete  the 
separation.  When  the  synovial  membrane  is  opened  above  the  patella, 
the  operator  carried  the  dissection  upward,  opening  the  joint  cavity 
completely  under  the  muscles  laying  bare  the  uppermost  cul-de-sac. 

The  patella  ligament  is  split  separating  it  into  two  lateral  halves,  also 
the  sub-ligamentous  fat;  each  half  of  the  patella  is  now  retracted  and  the 
knee  flexed  allowing  a  good  view  of  the  joint  and  the  crucial  ligaments. 

This  incision  will  give  a  complete  view  of  the  synovial  cavity  ante- 
riorly. Any  deranged  condition  having  been  remedied,  the  knee  is 
straightened,  the  quadriceps  entensor  and  the  joint  cavity  beneath  it 
are  carefully  brought  together  with  chromic  catgut  sutures  number  00 
down  to  the  patella.  Silk  or  kangaroo  tendon  is  used  to  bring  the  soft 
tissues  together  immediately  at  the  upper  end  of  the  patella  and  imme- 


72  TECHNIQUE  OF  OPERATIONS 

diately  at  the  lower  end  of  the  patella.  When  for  any  reason  these 
materials  are  undesirable  or  not  available,  chromic  catgut  sutures  num- 
ber 0  or  00  may  be  used.  No  sub-patella  patella  sutures  are  necessary; 
the  halves  of  the  patella  are  carefully  adjusted  and  the  sutures  placed 
in  the  overlying  fascia.  Sometimes  there  is  a  little  blood  left  in  the  joint 
but  this  will  do  no  harm.  As  a  rule  washing  with  salt  solution  will  re- 
move any  that  is  present.  Anj^  very  small  amount  of  free  blood  will  not 
interfere  with  convalescence.  The  muscles  and  overlying  tissues  having 
been  brought  together  with  interrupted  chromic  catgut  sutures  number 
00,  the  skin  and  fat  are  brought  together  with  continuous  chromic 
catgut  sutures  number  00.  A  posterior  wire  splint  or  a  metal  splint 
holding  the  knee  very  slightly  flexed  is  applied  and  a  plaster  may  be 
used  over  this.  If  a  plaster  is  used  it  should  be  removed  on  the  third 
or  fifth  day.  Gentle  motion  is  begun  on  the  fifth  or  seventh  day  and  as 
the  patient  progresses,  he  is  encouraged  to  use  the  muscles  and  may  be 
up  with  crutches  at  the  end  of  ten  to  fourteen  days.  In  the  fourth  week, 
he  is  encouraged  to  bear  a  little  weight  on  the  leg. 

80.  Arthrotomy. — A  knowledge  of  the  important  routes  of  ap- 
proach to  the  joints  will  facilitate  any  joint  exploration,  the  removal  of 
foreign  bodies,  the  repair  of  traumatic  conditions,  the  adjustment  of 
difficult  fractures,  the  reduction  of  old  and  difficult  dislocations,  to 
mobilize  joints  where  motion  is  partially  or  totally  lost,  and  to  restrict 
or  stiffen  the  joint  as  in  certain  paralytic  conditions,  to  relieve  and 
thoroughly  drain  suppurative  conditions;  a  knowledge  of  the  important 
routes  of  approach  to  the  joint  is  very  important.  For  each  case,  the 
operator  will  select  the  incision  best  suited  for  the  individual  condition. 
Joint  operations  should  never  be  hastily  considered  and  should  be 
avoided  by  any  one  not  familiar  with  the  best  surgical  technique. 

In  all  operations  on  the  joints,  the  incision  should  be  made  down  to 
the  synovial  membrane  and  large  enough  before  opening  the  synovial 
cavity.  All  bleeding  should  be  stopped  and  the  synovia  carefully 
opened.  The  joint  structures  should  be  tampered  with  as  little  as  pos- 
sible, the  synovial  membrane  brought  carefully  together  and  the  layers 
over  it  closed  in  order  not  to  disturb  the  function  of  the  periarticular 
tissues.  Unnecessary  separation  of  the  tissue  layers  is  to  be  avoided. 
Any  ligaments  that  must  be  cut  should  be  loosened  periosteally  when 
possible,  in  order  that  they  may  be  easily  replaced.  Early  motion 
should  be  the  rule,  gentle  at  first,  and  gradually  increased. 

81.  Arthrotomy  at  the  Knee. — Arthrotomy  at  the  knee  is  indicated 
for  certain  internal  derangement,  for  the  removal  of  foreign  bodies  or 
loose  bodies,  derangement  of  the  semilunar  cartilage,  suppurative  con- 
ditions, fractures,  etc.  For  a  good  view  of  the  joint  and  complete  ex- 
ploration of  the  anterior  cul-de-sacs  an  anterior  median  incision  through 
the  patella  is  the  best.  This  will  give  an  extensive  view  of  the  synovial 
pouches  anteriorly,  as  well  as  all  other  anterior  structures.  The  internal 
semilunar  lateral  incision  is  more  useful  for  derangement  of  the  inter- 


INCISION,  PUNCTURES  AND  ARTHROTOMY 


73 


nal  semilunar  cartilage;  the  external  is  rarely  deranged,  an  external 
semilunar  will  give  ready  access  to  the  outer  semilunar.  This  cartilage 
is  rarely  the  cause  of  trouble.  For  plastic  operation  the  two  longitudinal 
antero-lateral  incisions  are  generally  preferred.  For  excision  or  arthro- 
desis the  semilunar  or  "U"  shaped  incision  is  used.  For  drainage, 
numerous  incisions  have  been  recommended. 

The  operator  should  not  neglect  the  upper  and  lower  parts  of  the 
synovial  cavity  anteriorly  and  the  joint  cavity  behind  in  any  extensive 
suppurative  conditions. 

For  displacement  of  the  knee  cap  which  is  usually  displaced  outward, 
an  antero-lateral  incision  will  allow  the  tears  in  the  capsule  to  be  rem- 
edied and  give  access  to  the  patella  tendon  which  should  be  displaced 
as  described  in  these  pages  elsewhere. 

For  pre-patella  bursitis  a  longitudinal  incision  just  to  the  side  of  the 
bursa  is  used. 

For  fractures  of  the  patella  a  long  median  incision  is  made  or  a  lateral 
just  to  the  inner  side  of  the  patella  but  long  enough  through  the  skin 
and  fat  to  allow  retraction  and  complete  exposure  of  the  patella. 

82.  Anterior  Median  Incision.  Splitting  the  Patella  into  Lateral 
Halves. — This  incision  is  useful  where  a  complete  view  is  desired  of  the 
joint  and  its  an- 
terior cul-de-sacs. 
It  is  useful  for  ob- 
scure internal  de- 
rangement, for 
inspection  and  re- 
pair of  the  crucial 
ligaments,  for  the 
removal  of  loose 
bodies  or  pannus 
formation  and  for 
cleaning  out  the 
joint  in  septic  con- 
ditions. It  gives  Fig.  116 
a  wide  view  of  the 
knee  and  the  most  complete.  This  incision  is  not  the  best  for  reaching 
the  semilunar  cartilages.  There  is  surprisingly  little  reaction  following 
this  operation.     See  figures  116,  117. 

The  patient  lies  on  his  back,  the  operator  stands  on  the  side  of  the  leg 
to  be  operated  upon.  An  esmark  rubber  bandage  and  tourniquet  is 
applied,  the  skin  having  been  prepared  with  scrupulous  care  as  to  aseptic 
detail;  sterile  sheets  cover  the  upper  third  of  the  thigh  and  lower  leg 
and  foot  from  two  inches  below  the  tibial  tubercle.  Occasionally  the 
esmark  and  tourniquet  may  be  omitted,  if  there  is  any  reason  for  haste. 

An  incision  is  made  in  the  median  line  (see  figure  114),  starting  from 
the  patella  and  inclining  slightly  to  the  inner  side,  four  inches  upward. 


Anterior  me- 
dian incision. 


Fig.  117.  —  Anterior  median 
incision  retracted,  knee  flexed 
showing  view  of  crucial  liga- 
ments. 


74  TECHNIQUE  OF  OPERATIONS 

The  incision  extends  over  the  patella  and  below,  in  the  median  line,  to 
just  below  the  adductor  tubercle.  The  dissection  is  carried  down  in 
one  layer  through  the  skin  and  fat,  the  edges  of  which  are  dissected  up 
and  retracted.  At  this  point,  the  operator,  if  he  wishes,  may  additionally 
protect  the  incision  by  clamping  sterile  towels  to  the  retracted  edges  of 
the  skin  and  fat  and  use  fresh  instruments  for  completing  the  operation. 
The  surgeon  may  proceed  in  one  of  two  ways. 

(A)  Dissecting  through  the  tendon  above  the  patella,  extending  up- 
ward and  inclining  slightly  to  the  inner  side  of  the  median  line,  then 
splitting  the  tendon  below  the  median  line  before  sawing  the  patella. 

(B)  Or  the  tendon  above  and  below  the  patella  is  split  a  little  way 
before  sawing  the  patella. 

With  the  leg  straight  the  patella  is  sawed  two-thirds  through,  the 
knee  is  now  flexed  forty-five  degrees  and  a  sharp  osteotome  used  to 
complete  the  separation,  then  the  tendon  above  is  divided  inclining 
to  the  inner  side  of  the  median  line  and  the  tendon  below  is  split  in  the 
median  line.  A  better  exposure  of  the  joint  is  possible  if  the  patella  is 
cut  to  the  inner  side  of  the  median  line  as  there  is  less  mobility  of  the 
inner  fragment  (suggested  by  Dr.  Brackett). 

When  the  synovial  membrane  is  opened  above  the  patella,  the  operator 
carries  the  dissection  upward,  opening  the  joint  cavity  completely 
under  the  muscles,  laying  bare  the  uppermost  cul-de-sac.  The  knee  is 
flexed  ninety  degrees  and  the  patella  retracted  laterally. 

The  patella  ligament  is  split,  separating  it,  also  the  sub-ligamentous 
fat.  Each  half  of  the  patella  is  now  retracted  and  the  knee  flexed  allow- 
ing a  good  view  of  the  joint  and  the  crucial  ligaments. 

The  dissection  of  the  tendon  above  should  be  carefully  made  so  that 
it  may  be  accurately  approximated  afterwards.  The  fat  pad  under  the 
patella  should  be  split  in  the  median  line,  and  its  ligament  on  the  inner 
side  carefully  adjusted  when  the  sutures  are  placed,  bringing  the  fat' 
pad  together  in  its  original  position. 

Any  deranged  condition  having  been  remedied,  or  loose  body  removed, 
the  knee  is  straightened,  the  quadriceps  extensor  and  the  joint  cavity 
beneath  it  are  carefully  brought  together  with  chromic  catgut  sutures 
number  00  working  from  the  patella  upward.  The  joint  should  be 
handled  as  little  as  possible.  Silk  or  kangaroo  tendon  is  used  to  bring 
the  soft  tissues  together  immediately  at  the  upper  and  lower  end  of  the 
patella.  When  for  any  reason  these  materials  are  undesirable  or  not 
available,  chromic  catgut  sutures  number  0  or  00  may  be  used.  The 
halves  of  the  patella  are  carefully  adjusted  and  the  sutures  placed  in  the 
overlying  fascia.  No  other  patella  sutures  are  necessary.  Sometimes 
there  is  a  little  blood  left  in  the  joint.  This  will  do  no  harm.  As  a  rule, 
washing  with  salt  solution  will  remove  any  that  is  present.  Any  very 
small  amount  of  free  blood  will  not  interfere  with  convalescence.  The 
muscles  and  overlying  tissues  are  brought  together  with  interrupted 
chromic  catgut  sutures  number  00,  the  skin  and  fat  brought  together 


INCISION,  PUNCTURES  AND  ARTHROTOMY  75 

with  continuous  chromic  catgut  sutures  number  00;  a  dry  dressing  is 
applied.  A  posterior  wire  splint,  holding  the  knee  very  slightly  flexed, 
is  used  and  a  plaster  may  be  used  over  this.  If  the  plaster  is  used,  it 
should  be  removed  on  the  fifth  day.  Gentle  motion  is  begun  on  the 
fifth  or  seventh  day  by  pressing  with  the  hand  in  the  popliteal  space  and 
raising  the  knee,  letting  the  heel  rest  on  the  bed.  As  the  patient  pro- 
gresses, he  is  encouraged  to  use  the  muscles  and  may  be  up  with  crutches 
at  the  end  of  ten  to  fourteen  days.  In  the  fourth  week,  he  is  encouraged 
to  bear  a  little  weight  on  the  leg. 

When  there  is  restricted  motion  in  the  knee,  it  is  sometimes  impossible 
or  difficult  to  flex  the  knee  without  injury.  In  these  cases,  the  patella 
is  separated  with  the  knee  straight. 

In  the  aged,  or  where  the  health  is  not  good,  when  this  operation  is 
done  for  low  grade  painful  suppurating  conditions,  it  is  often  nec- 
essary to  operate  quickly  and  spend  time  in  wiping  out  the  cavity 
or  in  freeing  it  of  foreign  material.  In  these  cases,  the  incision  is 
made  rapidly  through  the  skin  and  fat  as  above  described  and  dis- 
sected back  only  enough  to  recognize  the  tendons  and  to  expose 
the  patella.  This  is  sawed  rapidly  two-thirds  through.  An  osteotome 
is  used  to  complete  the  separation.  The  upper  synovial  cavity  is  rapidly 
opened  with  a  pair  of  blunt  scissors  curved  on  the  flat  side.  The  lower 
jaw  of  the  scissors  is  entered  into  the  joint  above  the  patella  and  lifts 
the  tendon  and  synovia,  cutting  it  upward  and  extending  slightly  to  the 
inner  side  of  the  median  line.  The  tendon  below  is  split  through  with 
the  knife  and  the  joint  laid  open  completely.  The  knee  is  flexed  at  right 
angles.  In  these  cases  requiring  haste,  the  joint  is 
carefully  treated.  The  important  sutures  are  used, 
one  or  two  in  the  sub-patella  fat,  a  heavy  one  above 
and  below  the  patella  and  a  continuous  chromic  catgut 
suture  00  in  the  fibrous  tissue  over  the  patella.  If 
there  is  time,  the  synovial  cavity  is  closed  slowly  and 
carefully, — if  not,  it  is  sutured  rapidly  with  the  tendon 
by  a  continuous  chromic  catgut  number  00. 

If  drainage  is  necessary,  tubes  are  placed  into  large 
punctures  at  the  side  of  the  joint  made  before  the  in- 
cision is  closed.  This  rapid  operation  has  been  done  in 
patients  over  sixty  years  of  age. 

With  a  painful  infected  condition,  requiring  open 
operation,  ultimate  recovery  is  possible  in  some  cases,      ^IG-  .n8-  —  Pos- 
with  sixty  to _ ninety _  degrees  of  motion.  £^era  C^^g 

83.  Posterior  Incision. — The  posterior  incision  is  in  the  median  line 
used  for  loose  bodies  in  the  posterior  part  of  the  joint  t£re?  . mclies  above 
or  the  removal  of  the  exostosers,  or  for  drainage  when 
anterior  and  lateral  drainage  is  not  sufficient.  A  long  vertical  posterior 
median  incision  is  made  five  inches  long  starting  three  inches  above  the 
joint  line  which  may  be  felt  in  front.     The  incision  is  carried  down 


70 


TECHNIQUE  OF  OPERATIONS 


through  the  skin  and  fat  for  the  full  length.  A  blunt  instrument  is  then 
used  separating  the  tissues  between  the  outer  side  of  the  vessels  and  the 
biceps  and  outer  head  of  the  gastrocnemius.  The  tissues  are  then  re- 
tracted and  the  synovial  membrane  opened.     See  figure  118. 

84.  The  Bayonet  Incision  at  the  Knee. — This  incision  combines 
half  the  outer  and  half  of  an  inner  vertical  incision  with  a  cross  incision 
over  the  patella  or  just  below  it.  Whether  the  upper 
or  the  lower  half  is  outward  is  a  matter  of  choice.  In 
order  not  to  weaken  the  inner  attachments  of  the 
patella  to  the  tibia  the  upper  portion  of  the  bayonet  in- 
cision had  better  be  made  one-half  inch  to  the  inner 
side  of  the  patella  starting  three  inches  above  the 
patella,  extending  across  the  patella  one-half  inch  to 
its  outer  side  and  then  downward  three  inches  (see  fig- 
ure 119).  The  cross  incision  is  not  made  at  right  an- 
gles but  inclines  downward.  In  certain  fractures  and 
injuries  this  incision  will  be  found  of  advantage.  For 
a  rapid  excision  in  cases  where  the  circulation  is  poor 
and  the  object  of  the  excision  is  to  obtain  a  stiff  knee 
by  grafting  as  well,  this  incision  has  many  advantages. 
It  is  vertical  and  interferes  very  little  with  the  circula- 
tion considering  the  size  and  the  good  exposure  of  the 
joint.  The  incision  gives  access  to  the  tibia  below,  al- 
lowing a  bone  graft  to  be  removed  and  placed  across 
the  excised  joint,  as  suggested  by 
Albee. 

85.  Two  Lateral  Incisions  at  the 
Knee  (Fig.  120). — For  exploratory 
arthrotomy  or  for  suppurative  con- 
ditions the  median  incision  is  preferable,  but  in  cer- 
tain fractures  or  operations  on  the  tibia  and  femur 
or  on  both  bones,  one  or  two  lateral  incisions  are 
more  practical  than  the  anterior  median  incision.  In 
certain  suppurative  conditions  where  the  median  in- 
cision has  been  used  to  expose  the  joint  completely, 
two  short  lateral  incisions  may  be  used  for  the  neces- 
sary persistent  drainage  after  closing  the  anterior 
median. 

The  lateral  incision  extends  four  to  six  inches  on 
either  side  of  the  joint,  one  inch  from  the  patella  with 
their  middle  at  the  middle  of  the  patella.    These  incisions  are  preferable 
for  arthroplasty. 

A  longitudinal  incision  is  made  four  inches  long,  one  inch  to  the  inner 
side  of  the  patella,  starting  two  inches  above  the  joint.  The  incision 
is  carried  down  to  the  bone.  All  the  tissues  are  lifted  subperiosteal^ 
from  the  femur  and  from  the  tibia,  allowing  a  free  exposure  as  the  incision 


Fig.  119.— I.  U- 
shaped  and  Bayo- 
net incision  at  the 
knee.  II.  Bayonet 
incision;  the  up- 
right portions 
should  be  one-half 
or  one  inch  outside 
or  inside  of  the  pa- 
tella. The  horizon- 
tal portion  may  be 
over  or  just  below 
the  patella. 


Fig.  120.  —  Two 
lateral  incisions  at 
the  knee. 


INCISION,  PUNCTURES  AND  ARTHROTOMY  77 

is  retracted  forward,  and  backward.  A  second  incision  is  made  ex- 
tending four  inches  above  and  three  inches  below  the  joint  line  and  one 
inch  to  the  outer  side  of  the  patella. 

86.  The  U-Shaped  Incision  at  the  Knee  (Fig.  119). — An  outer  incision 
is  started  three  inches  above  the  joint  extending  vertically  downward 
one-half  inch  outside  of  the  patella  down  to  the  level  of  the  tubercle  of 
the  tibia  and  then  horizontally  across  the  tibia  and  extending  vertically 
upward  parallel  to  the  first  incision  and  one-half  inch  to  the  inner  side 
of  the  patella  extending  to  a  point  three  inches  above  the  joint.  The 
incision  is  carried  down  to  the  bone  if  an  excision  is  to  be  done.  If  the 
joint  is  to  be  opened  and  explored  the  incision  is  to  be  carried  down  to 
the  capsule  only.  When  the  flap  is  retracted  the  synovial  cavity  is  care- 
fully opened. 

87.  Arthrotomy  for  Fractures  About  the  Joints. — The  necessity  of 
immediate  operation  in  fracture  about  the  joints  depends,  as  in  other 
fractures,  on  the  acuteness  of  the  local  and  general  reaction.  When 
these  do  not  contra  indicate  immediate  operation,  certain  fractures  about 
the  joint  may  require  treatment  by  the  open  method.  Among  these  are 
fractures  of  the  patella,  fracture  of  the  olecranon  and  certain  fractures 
of  the  surgical  neck  of  the  humerus  and  certain  fractures  of  the  neck 
of  the  femur,  all  compound  fractures,  even  when  the  protrusion  of  the 
bone  has  been  extremely  slight,  all  fractures  that  cannot  be  maintained 
or  where  apposition  is  impossible,  many  fractures  combined  with  dis- 
location, articular  fractures  with  pieces  locking  or  limiting  the  joint 
action. 

Where  there  is  a  great  deal  of  trauma  and  in  multiple  fractures  and  in 
cases  where  there  is  a  great  deal  of  shock  all  that  can  be  done  is  to  im- 
mobilize the  parts  until  a  favorable  time  for  operation.  In  selecting  a 
suitable  time  for  operation  when  it  is  found  necessary  to  operate  on  a 
fracture  if  there  is  no  immediate  contra  indication,  the  sooner  it  is  done 
the  better.  Where  there  is  tremendous  swelling  the  surgeon  should  al- 
ways wait.  All  cases  should  be  operated  on  that  show  no  union  after 
three  months  of  good  treatment. 

Methods  of  treating  the  individual  fracture  cannot  be  considered 
in  a  limited  space  like  this.  The  writer  has  described  the  routes  of 
approach  to  the  different  joints  and  the  technique  of  these.  This  will 
enable  the  surgeon  from  his  knowledge  of  fractures  to  select  the  route 
best  adapted  for  the  individual  treatment  required  and  when  necessary 
two  or  more  incisions  may  be  used.  A  knowledge  of  the  technique  will 
enable  the  surgeon  to  work  rapidly  in  reaching  the  fracture  on  which 
he  expects  to  spend  time. 

88.  A  Method  of  Treating  Overlapping  Fractures. — Where  the  bones 
overlap,  an  excellent  method  of  treatment  is  one  suggested  to  the  writer 
many  years  ago  by  Dr.  Edward  Martin  of  Philadelphia.  In  the  opera- 
tion when  the  surgeon  has  reached  the  fracture  the  ends  are  freed.  A 
tough  tape  or  webbing  is  used  ten  or  twelve  feet  long,  sterilized.    The 


78  TECHNIQUE  OF  OPERATIONS 

two  ends  of  the  tape  are  tied  together,  a  loop  of  the  tape  is  placed  over 
the  distal  end  of  the  bone.  The  other  end  of  the  tape  is  thrown 
over  the  foot  of  the  operating  table,  a  thirty-five  pound  weight 
is  attached  to  this  by  an  assistant.  In  about  five  minutes  the  bones 
will  be  found  to  be  separated  at  least  one  inch.  The  weight  is  then  held 
up  by  a  non-sterile  assistant,  the  tape  taken  off  of  the  end  of  the  bone 
and  clamped  to  the  sheet  on  the  operating  table,  so  that  it  will  not  slip 
away  while  the  surgeon  works  on  the  fracture.  When  the  muscles  are 
in  fairly  good  tone  or  the  overlapping  of  bone  has  been  great,  it  will  be 
found  that  the  bones  will  overlap  again  in  four  or  five  minutes.  A  re- 
application  of  the  tape  will  separate  the  bones  again  for  the  same  length 
of  time.  The  end  of  the  lower  bone  should  not  be  cut  or  freshened  until 
all  other  procedures  are  done  which  require  separation  of  the  bone. 
When  these  have  all  been  done  the  end  of  the  bone  over  which  the  tape 
has  been  placed  is  freshened.  After  this  the  tape  should  not  be  placed 
on  the  end  of  the  bone,  unless  it  is  very  necessary,  but  the  two  ends 
allowed  to  come  together  and  held  by  a  clamp  until  the  operation  is 
complete. 

Very  bad  overlapping  fractures  have  been  treated  in  this  way  in  fresh 
cases  without  the  necessity  of  shortening  the  bone.  In  old  fractures  no 
more  bone  need  be  removed  than  is  required  by  the  conical  condition 
of  the  ends  of  the  bone. 

89.  Fractures  of  Long  Standing  Still  Ununited  or  United  with  De- 
formity, Preventing  Function. — In  fractures  of  long  standing  where 
there  is  a  mild  infection,  conservative  treatment  should  be  tried  first. 
When  this  has  been  tried  free  drainage  should  be  established  and 
at  the  same  time  the  ends  of  the  bone  freshened  up  slightly.  Unless 
the  infection  is  marked,  in  many  of  these  cases  when  the  infection 
disappears,  union  has  also  taken  place.  In  any  case  where  there  has  been 
infection,  no  plastic  operation  should  be  used  until  the  infection  has  been 
entirely  absent  for  at  least  nine  months,  a  year  is  safer.  Where  the  in- 
fection is  very  mild  and  of  long  standing,  during  the  process  of  treatment 
the  patient  may  be  allowed  to  walk  on  the  other  leg  if  the  local  reaction 
is  not  too  great.  Sometimes  he  may  walk  a  little  on  the  affected  leg. 
It  is  of  advantage  in  certain  cases  to  use  a  Thomas  splint  to  take  some 
of  the  weight  off  of  the  affected  leg,  the  patient  being  allowed  to  bear 
weight  on  the  ball  of  the  foot,  the  splint  taking  all  the  weight  off  of  the 
heel.  Where  the  x-ray  shows  conical  bone  ends  it  is  practically  useless 
to  expect  union  without  surgical  interference. 

90.  Fracture  of  the  Patella. — Fractures  of  the  patella  usually  re- 
quire treatment  by  the  open  method.  Where  the  fracture  is  not  com- 
pound the  joint  should  be  disturbed  as  little  as  possible,  the  fragments 
adjusted  and  sutured,  if  possible,  by  absorbable  material.  The  suturing 
of  the  patella  may  require  drilling  the  bone.  The  drill  holes  should 
not  be  made  through  to  the  under  surface  of  the  patella  but  from  the 
fracture  to  the  front  of  the  patella.    Multiple  irregular  fractures  are  often 


INCISION,  PUNCTURES  AND  ARTHROTOMY  79 

very  difficult  to  treat.  Too  perfect  adjustment  at  the  expense  of  exces- 
sive manipulation  is  not  desirable  in  extremely  difficult  cases.  A  simple 
transverse  fracture  may  be  sutured  with  kangaroo  through  the  perios- 
teum and  overlying  fibrous  tissues.  The  knee  should  be  kept  straight 
in  plaster  three  weeks  and  then  gentle  passive  motion  without  force  is 
instituted  daily,  allowing  the  heel  to  rest  on  the  bed  while  the  knee  is 
being  slightly  flexed,  and  the  plaster  reapplied  afterwards.  The  plaster  is 
removed  a  part  of  each  day  after  the  fourth  week  and  gradually  omitted 
entirely.  The  patient  walks  on  the  leg  with  the  plaster  and  crutches  in 
four  weeks. 

91.  Fractures  into  the  Knee  Joint.— Fractures  and  oblique  frac- 
tures into  the  knee  joint  will  often  require  open  operation  and  adjust- 
ment of  the  fragments.  Bone  grafts,  plates  or  phospho  bronze  or  silver 
wire  may  need  to  be  used.  The  lower  end  of  the  femur  is  accessible  from 
the  sides  through  vertical  incisions  just  anterior  to  the  condyles  posterior 
enough  to  avoid  opening  the  joint  capsule.  The  upper  tibia  is  reacted 
by  anterior  incisions. 

92.  Operation  for  Dislocation  of  the  Patella. — When  the  patella  is 
excessively  loose  and  dislocates  easily,  the  simplest  operation  is  that 
described  by  Dr.  Goldthwait  "splitting"  the  patella  tendon.  The  dis- 
placement of  the  patella  is  usually  outward.  It  reduces  itself  but  has 
torn  the  inner  capsule  which  becomes  stretched,  giving  a  predisposition 
to  future  dislocation. 

OPERATION 

An  esmark  and  tourniquet  is  applied,  the  usual  preparation  and 
protection  of  the  field  of  operation  is  used.  An  incision  is  made  three 
inches  long  to  the  inner  side  of  the  median  line  extending  from  the  middle 
of  the  patella  downward.  The  skin  and  subcutaneous  tissues  are  re- 
tracted in  one  piece  exposing  the  patella  tendon.  This  is  raised  on  a 
blunt  instrument  and  slit  longitudinally;  the  outer  half  is  detached 
subperiosteally,  slid  under  the  inner  half  and  reattached  by  quilted 
sutures  to  the  periosteum  to  the  inner  side. 

The  deep  tissues  are  brought  together  with  interrupted  chromic 
catgut  sutures  number  00,  the  subcutaneous  fat  with  interrupted 
chromic  catgut  sutures  number  00,  the  skin  with  continuous  chromic 
catgut  sutures  number  00. 

A  small  dressing  is  applied  and  a  plaster  of  Paris  bandage  from  the 
toes  to  the  groin.  It  is  split  on  both  sides.  Slight  knee  flexion  is 
allowed  in  six  weeks;  walking  with  the  plaster  on  in  eight  weeks.  The 
plaster  is  gradually  omitted  after  that. 

93.  Tapping  the  Knee  Joint. — The  most  scrupulous  aseptic  pre- 
cautions are  necessary  both  as  to  the  preparation  and  the  protection  of 
the  field  of  the  operation.  The  knee  may  be  tapped  under  the  vastus 
internus,  the  vastus  externus  or  posterior  to  the  outer  border  of  the 
patella.    The  operator  uses  the  other  hand  or  has  an  assistant  press  the 


80  TECHNIQUE  OF  OPERATIONS 

swelling  from  the  other  side  of  the  joint.  This  makes  it  easier  to  insert 
the  trocar.    It  may  be  advisable  to  wash  out  each  joint  pocket  separately. 

When  there  is  much  effusion  it  is  not  difficult  to  reach  the  joint.  The 
skin  is  drawn  to  the  side  so  that  the  hole  in  the  skin  and  muscle  will  be 
out  of  line  when  the  needle  is  removed.  If  fluid  is  to  be  drawn,  and  other 
solutions  are  to  replace  it,  the  amounts  should  be  carefully  measured. 
Two  good  graduated  metal  syringes  are  used,  one  used  to  aspirate,  one  to 
inject.  All  of  their  parts  should  be  tested  beforehand.  The  trocar  is 
made  to  enter  the  joint  and  then  is  connected  with  the  syringe.  As  little 
air  as  possible  should  enter  the  joint.  The  trocar  should  be  of  large 
diameter  as  the  fluid  may  be  thick  or  flaky.  When  the  patient  is  not 
anaesthetized  for  the  operation  it  is  often  well  to  have  a  short  flexible 
tube  connect  the  trocar  with  the  syringe.  This  should  be  fastened  at 
both  ends  by  silk  ties  so  that  it  will  not  leak  easily  when  pressure  or 
suction  is  used.  If  the  joint  is  to  be  washed  out  a  definite  amount  of 
fluid  is  injected  and  the  return  measured  in  a  sterilized  measuring  glass. 
When  the  process  is  complete  the  amount  of  fluid  left  in  the  knee  joint 
should  not  exceed  one  and  a  half  ounces.  This  amount  will  not  cause 
pain  or  too  much  distension  in  an  adult  knee. 

Dr.  Murphy  uses  a  formalin  glycerine  solution  as  follows: — Liquor 
formaldehyde  2%  in  glycerine,  about  ten  drops  of  the  formaldehyde  to 
each  ounce  of  glycerine.  This  acts  very  well  in  infectious  synovitis. 
But  it  should  not  be  used  in  arthritis  deformans  nor  in  old  chronic 
arthritis. 

The  tapping  may  be  done  with  ethyl  chlorid  or  novocaine  adreneline 
solution,  1%.  The  solution  should  be  prepared  twenty-four  hours 
before  it  is  used. 


CHAPTER  V 

OPERATIVE   TREATMENT   IN    CASES   OF   JOINT   ANKYLOSIS 

94.  Excision  of  the  Knee  to  Obtain  Ankylosis. — An  esmark  rubber 
bandage  is  applied  from  the  toes  to  the  groin  and  a  tourniquet  applied 
at  the  upper  part  of  the  thigh.  The  esmark  is  removed,  the  skin  of  the 
leg  prepared  for  operation,  and  the  leg  protected  with  sterile  sheets. 
A  bayonet  incision  (see  section  84),  or  a  U-shaped  incision,  is  made 
starting  two  inches  above  the  joint  and  one  inch  to  the  side  of  the 
patella  extending  vertically  downward  to  the  level  of  the  tuberosity  of 
the  tibia,  then  horizontally  across  the  tibia,  and  up  on  the  side,  one  inch 
from  the  patella  to  a  point  one  and  one-half  inches  above  the  joint.  The 
sides  of  the  "U"  should  be  parallel,  and  about  one  inch  from  the  edges 
of  the  patella.  The  incision  is  carried  down  to  the  bone  and  the  flap 
dissected  up  rapidly  in  one  piece.  The  ligamentum  patellae  is  cut  across 
or  the  patella  may  be  sawed  through;  the  soft  tissues  are  dissected  up 
from  the  femur.  The  tissues  are  removed  from  the  bone  preferably 
with  the  periosteum.  The  tibia  is  likewise  exposed  preferably  sub- 
periosteally  and  the  tissues  retracted.  Any  disease  of  the  soft  tissues  is 
now  cleaned  away.  The  knee  is  next  flexed  acutely,  the  crucial  liga- 
ments cut  and  the  joint  surface  brought  into  view.  The  lower  end  of 
the  femur  is  brought  forward  by  displacing  the  tibia  backward,  the  soft 
tissues  removed  subperiosteally  from  its  posterior  surface.  The  upper 
end  of  the  tibia  is  next  brought  forward  by  displacing  the  femur  back- 
ward, the  knee  being  flexed.  The  soft  tissues  are  removed  subperios- 
teally from  the  back  of  the  tibia.  There  is  no  danger  of  injuring  the 
nerve  and  vessels  by  this  subperiosteal  method.  The  operator  should 
work  carefully  but  rapidly.  A  thin  slice  is  removed  from  each  bone  in 
such  a  way  that  when  the  bone  surface  will  be  brought  together  the  knee 
will  be  flexed  ten  or  fifteen  degrees.  The  bones  are  held  perpendicular 
to  the  table  while  the  saw  is  being  used,  usually  the  tibia  first.  In 
children  the  epiphysial  line  should  be  avoided.  Save  as  much  bone  as 
possible.  The  bones  should  be  placed  in  line  as  viewed  from  the  front 
and  in  10  degrees  of  flexion. 

When  the  operation  is  one  for  disease  of  the  bone  the  diseased  focuses 
are  cut  out  with  an  osteotome  or  chisel  in  the  healthy  bone  around  the 
diseased  cavity,  the  cavity  is  chiselled  out  carefully,  and  all  the  disease 
removed.  It  is  better  not  to  use  a  curette  for  this  purpose.  The  slice 
of  bone  removed  from  the  tibia  or  femur  need  not  be  thick  if  the  cavities 
are  chiselled  out.  There  is  very  little  shortening  of  the  leg  by  this 
method. 

When  the  operation  is  done  not  for  disease  but  to  stiffen  the  knee, 

81 


82  TECHNIQUE  OF  OPERATIONS 

only  a  very  small  slice  is  removed  from  each  bone.  After  removal  of 
bhe  bone,  the  tissues  are  washed  with  hot  saline  solution  and  the  tour- 
niquet loosened  to  allow  any  bleeding  points  to  be  caught  and  tied. 
When  it  is  necessary  to  remove  a  good  deal  of  bone  with  the  saw,  the 
tissues  must  be  .very  completely  dissected  away  subperiosteally  from 
the  front  and  back  of  the  tibia  as  well  as  from  back  and  front  of  the 
femur  so  that  they  may  be  retracted  allowing  fully  an  inch  of  the  bone 
to  protrude  denuded  of  periosteum. 

In  fitting  the  bones  together,  any  tendency  to  bow  leg  or  knock  knee 
should  be  corrected.  The  operator  should  repeatedly  notice  the  position 
of  the  foot  and  the  direction  which  it  is  pointing  before  he  removes  the 
bone  from  the  tibia,  as  it  is  very  easy  for  the  tibia  to  be  inwardly  or 
outwardly  rotated  during  the  operation.  The  bones  are  placed  in 
apposition  and  may  be  held  there  by  bone  graft  from  the  same  leg 
by  bone  plates  by  kangaroo  or  silver  wire  sutures.  The  bone  ap- 
position should  be  very  perfect  and  the  bones  held  firmly  together 
in  order  that  perfect  union  will  be  obtained.  The  operation  should 
be  done  without  any  unnecessary  waste  of  time.  The  deep  tissues 
and  periosteum  are  brought  together  with  interrupted  chromic  catgut 
sutures  number  00,  the  deep  tissues  with  interrupted  chromic  catgut 
sutures  number  00.  A  posterior  metal  or  wire  splint  properly  padded 
and  bent  to  the  desired  angle  made  ready  before  the  operation  is  now 
applied  directly  to  the  leg.  A  plaster  of  Paris  is  applied  over  this  includ- 
ing the  foot  and  extending  well  up  into  the  groin.  This  should  remain 
in  position  for  at  least  four  weeks.  The  dressing  is  inspected  through 
a  window  cut  in  the  plaster. 

Weight  bearing  is  allowed  in  the  fifth  or  sixth  week  if  there  is  no  disease 
and  very  little  reaction  at  that  time.  When  the  operation  is  done  to 
remove  disease  there  is  often  too  much  reaction  for  weight  bearing  for 
a  long  time  after  the  patient  is  allowed  to  be  up  and  about.  In  the  severe 
cases  there  is  sometimes  sinus  formation  but  the  ultimate  healing  occurs 
in  a  much  shorter  time  than  if  the  operation  were  not  done.  In  these 
cases,  weight  bearing  will  not  be  tolerated  so  early. 

Excision  of  the  knee  is  rarely  necessary  after  injury.  Where  there  is 
flexion  deformity,  a  McEwen  osteotomy  is  preferable  to  any  operation 
on  the  joint.    This  is  especially  so  if  there  is  any  motion  in  the  joint. 

Excision  or  erasion  of  the  knee  joint  may  be  used  in  paralytic  cases 
to  give  a  stiff  knee  when  there  is  no  power  in  the  muscles.  Before  doing 
an  excision  for  disease  of  the  bone,  conservative  treatment  and  drainage 
should  be  tried  first. 

It  has  been  recommended  to  transfer  the  posterior  muscles  to  the  side 
of  the  knee  to  prevent  any  tendency  to  flexion  or  subluxation.  This 
should  not  be  necessary  and  will  prolong  the  operation  which  is  usually 
done  on  patients  with  lowered  local  or  general  conditions  or  both. 

95.  Arthroplasty  for  Ankylosis  of  the  Knee. — Ankylosis  may  be 
bony,  cartilaginous  or  fibrinous,  it  may  be  periarticular,  ligamentous 


OPERATIVE  TREATMENT  OF  JOINT  ANKYLOSIS  83 

and  capsular,  or  extra  articular,  that  is,  skin  scars,  tendons,  fascia, 
nerves  and  arteries. 

The  form  of  ankylosis  that  exists  will  determine  the  treatment.  A 
partial  ankylosis  at  certain  points  had  better  not  be  treated  by  an 
arthroplasty. 

Age  must  be  considered,  also  the  general  condition  of  the  patient. 
When  the  ankylosis  is  bony,  cartilaginous  or  fibrinous,  arthroplasty  is 
indicated.  When  the  condition  is  periarticular  or  extra  articular,  it  may 
be  treated  by  capsulotomy,  tendon  elongation,  excision  of  exostosies,  etc. 

Dr.  Murphy  lays  stress  on  the  following  points: — The  principles  of 
asepsis  to  the  finest  detail  are  absolutely  essential.  One  not  familiar 
with  the  best  surgical  technique  should  avoid  arthroplastic  operations. 
The  exposure  of  the  joint  must  be  generous  and  complete.  The  con- 
tracted capsular  ligaments  and  soft  parts  must  be  freed  and  if  necessary 
lengthened.  The  normal  contour  of  the  joint  should  be  restored  as  near 
as  possible.  The  operator  should  obtain  a  hyper-mobilization  of  the 
joint.  The  joint  should  be  re-shaped  to  give  stability.  The  inter- 
position of  material  to  prevent  reunion  of  the  bone  is  necessary. 

The  principle  is  to  separate  the  bones  and  to  interpose  between  them 
material  to  prevent  ankylosis.  The  best  material  for  this  purpose  is  the 
human  pedicle  composed  of  fat,  muscle,  fascia  or  a  combination  of  these. 

When  this  is  not  possible,  a  transplantation  is  made  of  fat  and  fascia 
from  the  trochanter  bursa  region  or  from  the  fascia  lata. 

Materials  such  as  ivory,  celluloid  or  silver  are  not  good.  Materials 
that  will  not  absorb  or  that  absorb  too  slowly  are  not  desirable. 

During  the  operation  the  soft  parts  should  be  freely  liberated.  Attach 
the  interposing  flap  to  one  bone  only  and  cover  it  completely.  Early 
motion,  that  is,  at  the  end  of  five  to  seven  days,  is  necessary  with  or 
without  gas  or  gas  and  oxygen. 

Dr.  Murphy  records  failures  in  arthroplasty  as  due  to  first,  insufficient 
and  defective  exsection  of  the  capsule  and  ligaments,  second,  insufficient 
interposition  of  fat  and  fascia  between  the  separated  bony  surfaces, 
third,  infection,  fourth,  the  sensitiveness  to  pain  on  motion  after  opera- 
tion. 

Cases  of  primary  tuberculosis  and  cases  of  recent  infection  that  have 
subsided  are  not  suitable  cases  for  arthroplasty.  In  operation,  in  addi- 
tion to  the  usual  protection  of  the  field  of  operation,  after  the  skin  and 
fat  have  been  incised,  towels  should  be  clamped  to  the  edges  of  the  skin 
as  an  extra  protection. 

The  knee  is  the  least  favorable  joint  for  arthroplasty.  Operations  on 
the  knee  are  very  difficult  because  of  numerous  factors.  Among  these 
are  the  peculiarity  of  the  joint  and  the  fact  that  not  only  motion  must 
be  obtained,  but  good  weight  bearing  qualities.  There  must  be  firmness 
and  yet  free  use.  For  this  reason  if  the  ankylosis  is  only  partial  and  the 
knee  is  permanently  flexed  it  is  better  in  these  cases  to  do  a  McEwen 
osteotomy  above  the  abductor  tubercle  as  described  elsewhere  in.  tbrs? 


84  TECHNIQUE  OF  OPERATIONS 

pages  and  in  this  way  straighten  the  knee  without  trauma  and  give  the 
patient  a  straight  leg  with  the  benefit  of  the  motion  which  he  had  before 
the  operation  (see  Osteotomy  at  the  Knee,  section  54). 

When  the  ankylosis  is  complete  and  requires  an  arthroplasty  (see 
General  Considerations  in  Arthroplasty),  the  following  operation  is 
described  as  outlined  by  Dr.  Murphy. 


OPERATION 

The  patient  lies  on  his  back,  the  operator  stands  on  the  side  of  the  leg 
to  be  operated  upon.  The  field  of  operation  is  properly  protected  and 
the  leg  below  the  knee  so  covered  by  sheets  that  the  knee  may  be 
manipulated  without  disturbing  the  protection. 

A  longitudinal  incision  is  made  four  inches  long,  one  inch  to  the  inner 
side  of  the  patella,  starting  two  inches  above  the  joint.  The  incision 
is  carried  down  to  the  bone.  All  the  tissues  are  lifted  subperiosteally 
from  the  femur  and  from  the  tibia,  allowing  a  free  exposure  as  the  in- 
cision is  retracted  forward,  and  backward.  A  second  incision  is  made 
extending  four  inches  above  and  three  inches  below  the  joint  line  and 
one  inch  to  the  outer  side  of  the  patella.  The  subperiosteal  dissection 
is  continued  around  to  the  outer  and  anterior  side  of  the  femur  and 
tibia.  The  posterior  part  of  the  joint  is  not  disturbed;  a  curved  chisel 
is  used  to  separate  the  two  bones  and  give  them  the  normal  contours. 
A  cavity  is  made  in  the  tibia  to  receive  each  condyle  and  deep  enough 
to  permit  extension.  An  exaggerated  intracondylar  notch  and  ridge 
are  made. 

A  "  U  "  shaped  incision  may  be  used  instead  of  the  lateral,  the  sides 
of  which  are  either  side  of  the  patella,  extending  one  inch  above  the 
top  of  the  patella,  and  going  down  and  curved  one  inch  below  the 
patella.  The  skin  and  fascia  flap  are  made  carefully  without  disturbing 
the  pre-patella  bursa;  the  base  of  the  flap  is  upward. 

A  pedicle  flap  is  made  from  the  vastus  internus  and  another  from  the 
vastus  externus.  These  are  placed  over  the  condyles  and  between  the 
patella  and  the  condyles. 

If  the  operator  prefers,  he  may  use  two  rectangular  flaps  two  and  one- 
half  inches  by  three  and  one-half  inches,  composed  of  the  capsule  and 
the  subcutaneous  fat  with  a  base  downward  attached  to  the  tuberosity 
of  the  tibia  below  the  line  of  joint.  This  will  include  all  the  lateral 
capsule,  fat  and  fascia. 

As  to  the  choice  of  incisions,  the  two  lateral  incisions  are  preferable 
to  the  "  U  "  shaped. 

The  pedicles  for  arthroplasty  at  the  knee  may  be  taken  from  the 
vastus  internus  and  externus  as  described  above  with  the  pedicle  up- 
ward, or  the  fascia  over  the  muscles  may  be  split  from  above  downward 
into  two  parts  and  folded  over  the  joint  and  joined  at  the  middle  of  the 
joint  and  under  the  patella.     The  flaps  are  separated  with  a  blunt  in- 


OPERATIVE  TREATMENT  OF  JOINT  ANKYLOSIS  85 

strument  from  the  overlying  skin  and  fat  and  folded  in  between  the 
bones.  If  the  patella  has  been  adherent  it  may  be  rotated  one  hundred 
and  eighty  degrees  without  disturbing  the  pre-patella  bursa.  The 
upper  end  of  the  patella  may  need  to  be  trimmed  with  bone  forceps  to 
render  it  smooth  and  level  before  it  is  turned.  When  the  vasti  are 
used  in  this  instance,  the  vastus  internus  and  the  vastus  externus  are 
sutured  to  the  opposite  sides  of  the  quadriceps  from  which  they  are 
freed.  This  attachment  will  prevent  the  slipping  of  the  patella.  Baer 
has  used  successfully  chromicized  pig's  bladder  prepared  for  arthroplasty. 

Free  fascia  flap 

The  operator  may  choose  to  cover  the  under  side  of  the  patella  and 
the  whole  of  the  articular  surface  with  a  free  fascia  graft  taken  from  the 
fascia  lata.  This  is  attached  without  rotating  the  patella.  The  flaps 
are  sutured  to  the  patella  ligament  and  to  each  other  in  the  median  line. 
They  are  then  sutured  to  the  posterior  capsule  which  has  not  been  dis- 
turbed and  should  cover  the  tibia  completely.  When  a  free  fascial  trans- 
plant is  used,  it  should  be  at  least  three  and  one-half  by  five  inches.  It 
should  extend  up  under  the  patella.  A  carpenter  and  cabinet  maker 
chisel,  curved  and  straight,  will  give  the  best  tools  for  shaping  the  joint. 
The  normal  outlines  will  tend  to  prevent  luxation.  The  operator  should 
be  sure  that  the  line  of  the  leg  is  straight,  and  should  remove  sufficient 
amount  of  bone  so  that  pressure  between  the  bones  will  not  cause  ne- 
crosis of  the  transplanted  flap.  A  wire  splint  or  a  Buck's  extension 
with  twelve  pounds'  weight  is  used  after  operation.  Active  and  passive 
motions  should  be  begun  early.  The  patient  is  kept  in  bed  for  seven 
to  ten  days  with  this  apparatus. 


CHAPTER  VI 

OPERATION   IN   SUPPURATIVE    CONDITIONS 

96.  Suppurative  Conditions  at  the  Knee. — In  suppurative  condi- 
tions at  the  knee  joint  if  it  is  necessary  to  expose  and  wipe  out  the  whole 
joint  an  anterior  median  incision  will  allow  the  most  complete  inspec- 
tion, irrigation  and  wiping  out  the  cavity.  When  this  incision  is 
closed  the  pouches  on  either  side  and  above  the  patella  should  be 
drained  by  punctures  two  inches  long.  Drains  on  either  side  of  the 
patella  may  be  used  but  should  be  avoided  if  the  others  are  likely  to 
prove  sufficient. 

At  the  time  of  operation  two  lateral  incisions  may  be  necessary  in 
those  cases  that  require  thorough  irrigation,  and  tubes  are  inserted 
laterally.  The  important  parts  of  the  capsule  are  very  little  injured  by 
the  median  incision  with  lateral  drainage  and  the  operation  is  just  as 
quick  and  much  more  thorough  than  by  two  lateral  incisions. 

If  the  patient  will  not  stand  a  complete  operation,  two  incisions  are 
made  vertically  on  either  side  of  the  patella  for  drainage  only,  tubes  are 
placed  to  each  joint  pocket  and  gauze  is  used  to  gap  the  angles  of  the  in- 
cisions. These  remain  for  ten  days  and  then  are  shortened.  See  last 
half  of  section  82. 

A  plaster  of  Paris  bandage  is  applied  with  large  windows  as  shown  in 
figure  449.  Plaster  ropes  are  used  to  connect  two  plaster  cuffs,  one  at 
the  thigh,  the  other  on  the  calf  of  the  leg.  Large  wads  of  sheet  wadding 
are  placed  about  the  joint  to  hold  the  plaster  ropes  while  they  are  being- 
applied.  When  the  plaster  is  cut  away  exposing  the  plaster  ropes  the 
extra  sheet  wadding  is  removed  leaving  the  joint  exposed  for  inspection 
and  drainage.     See  Carrell  method,  section  323. 

97.  Osteomyelitis. — In  osteomyelitis  an  operation  should  be  done 
as  early  as  possible  after  making  the  diagnosis.  In  sub-acute  cases, 
incision  and  drainage  are  all  that  is  necessary.  Whenever  incising  for 
abscess  all  the  pockets  should  be  opened  and  if  the  abscess  is  large, 
counter  incisions  are  made  at  dependent  places.  The  pus  pocket  should 
be  opened  freely,  wiped  out  with  gauze,  irrigated  and  wiped  out  again 
with  gauze.  Curetting  should  be  avoided  excepting  for  the  removal  of 
sinuses  in  the  skin  and  in  cases  of  sinuses  it  is  often  better  to  excise 
them.  Perforated  rubber  tubing  should  be  placed  to  drain  the  deepest 
portions  of  the  pockets.  The  skin,  fat  and  superficial  muscle  layers 
should  be  made  to  gap  by  means  of  gauze  drains.  At  the  end 
of  ten  days  the  gauze  is  removed  and  the  tubes  shortened.  The 
tubes  are  gradually  drawn  out  a  little  each  day  or  two  until  not  used. 
This  method  makes  the  repeated  reapplication  of  drains  and  wicks 

86 


OPERATION  IN  SUPPURATIVE  CONDITIONS  87 

unnecessary  as  the  wound  will  gap  of  itself  and  close  from  the  bottom 
if  the  surgeon  has  been  careful  to  make  large  incisions. 

Where  the  periosteum  is  found  destroyed  or  the  pus  under  the  perios- 
teal layer,  the  bone  should  be  opened  by  means  of  a  large  drill  or  a  small 
gouge.  Where  this  is  necessary,  the  incisions  should  be  large  and  the 
counter  incision  should  be  made  on  the  other  side  of  the  bone  with  a  hole 
made  in  the  bone  a  little  above  or  a  little  below  the  hole  on  the  opposite 
side  (figure  65).  These  holes  in  the  bone  should  open  up  the  medullary 
cavity.  They  should  alternate  on  one  side  and  the  other  as  far  up  and 
down  as  the  disease  is  suspected.  When  the  abscess  is  very  great  and 
the  bone  involvement  is  large,  a  number  of  good  sized  holes  should  be 
made  with  a  Burr  drill  or  a  curved  gouge  on  both  sides  of  the  bone  as 
shown  in  figure  66.  The  wound  should  be  gaped  widely; — the  skin, 
fat  and  superficial  muscle  held  open  by  large  gauze  drains.  The  tubes 
should  reach  from  the  surface  to  the  deepest  portions  of  the  abscess 
cavity.  Splints  should  always  be  applied  to  immobilize  the  Limb. 
They  should  be  placed  so  that  they  will  not  interfere  with  the 
dressing.  In  some  instances  it  is  better  to  apply  plaster  with  large 
windows  and  ropes  to  give  stability  as  shown  in  figure  449.  The 
dressing  should  be  done  every  day  or  twice  a  day,  depending  on  the  foul 
condition  of  the  discharge.  If  the  odor  is  excessive;  chlorinated  soda 
dressing  should  be  used  diluted  72,  1jz  or  1ji  the  U.  S.  P.  strength.  The 
gauze  drains  should  be  left  for  at  least  ten  days  without  being  disturbed. 
When  removed,  granulations  will  be  formed  under  them  in  such  a  way 
as  to  keep  the  wound  open  without  applying  the  drains.  Irrigation 
may  be  used  at  the  time  of  operation  and  the  wound  thoroughly  wiped 
out  with  gauze  afterward.  No  irrigation  or  probing  or  application 
of  wicks  will  be  necessary  if  the  first  drain  is  left  in  long  enough.  After 
the  first  ten  days  the  tubes  are  shortened  up  gradually  until  they  are 
not  needed. 

Much  may  be  expected  in  the  future  from  the  Carrell-Dakin  solution 
and  technique.     See  section  323. 

In  severe  cases  where  the  patient  is  unconscious  or  delirious,  the  bone 
should  be  always  open,  three  or  four  holes  on  either  side  made  with  a 
good  size  Burr  drill.  In  no  case  should  the  incision  be  made  only  on  one 
side  of  the  leg  in  severe  cases.  No  tight  packing  should  be  used  as  this 
interferes  with  good  drainage.  Where  sequestra  have  formed  they 
should  be  removed.  An  x-ray  should  be  taken  whenever  possible  to 
determine  the  position  of  the  disease  (unless  the  case  is  urgent  and  an 
immediate  x-ray  is  not  obtainable). 

In  cases  of  long  standing  that  are  sub-acute  at  the  first  examination, 
where  the  bone  is  riddled  with  holes  over  an  extremely  long  area,  it  is 
impossible  often  to  remove  the  dead  bone  satisfactorily  without  removing 
all  the  bone.  In  these  cases  free  incision  down  to  the  bone  with  frequent 
openings  into  the  bone  as  described  above,  will  allow  the  septic  process 
to  run  its  course  and  the  sequestra  to  gradually  separate.    We  have  had 


88  TECHNIQUE  OF  OPERATIONS 

some  cases  in  which  the  lower  third  of  both  femora  were  riddled  with 
holes  and  full  of  sequestra,  the  patient  being  in  no  condition  for  extensive 
operation,  and  yet  not  very  ill.  In  these  cases,  however,  if  the  surgeon 
had  seen  the  patient  in  time  an  early  operation  would  have  prevented 
this  extreme  condition. 

Sometimes  it  is  necessary  to  close  a  large  bone  cavity  which  will  not 
heal  over.  Where  the  process  is  distinctly  septic  no  plastic  operation 
should  be  done  without  first  doing  an  operation  to  eliminate  the  septic 
condition.  After  that  part  of  the  muscle  may  often  be  transferred  over 
such  a  cavity  after  it  is  closed.  In  transferring  a  muscle  over  such  a 
cavity  it  should  be  freely  transplanted  and  held  there  without  tension. 
The  skin  should  be  brought  together  over  the  muscle  and  the  wound 
drained,  as  there  is  apt  to  be  inflammatory  disturbance. 

Where  sequestra  are  present  it  is  always  desirable  to  remove  them  as 
soon  as  they  have  separated  and  the  involucrum  is  strong  enough  to  act 
as  a  support.  Sequestra  may  be  superficial  or  in  the  medullary  cavity 
or  both.  Where  there  is  a  persistent  sinus  and  a  sequestrum  is  present, 
pus  will  continue  to  form  until  the  sequestrum  is  removed.  Cases  dis- 
charging several  years  where  a  sequestrum  is  present  may  close  in  a  few 
weeks  after  removal  of  the  sequestrum. 

In  closing  a  bone  cavity  its  edges  may  be  chiselled  clean  and  then  the 
bone  incised  a  short  distance  from  one  edge  and  parallel  to  it,  the  in- 
cision is  carried  down  to  the  medulla,  the  incision  in  the  bone  is  widened 
by  prying  it  open  and  forcing  the  bone  together  closing  the  old  cavity. 
This  is  sometimes  a  satisfactory  method  of  closing  an  old  open  bone 
cavity  which  has  sclerozed  edges. 

98.  Excision  of  the  Knee  in  Suppurative  Conditions. — When  an 
excision  of  the  knee  is  indicated  on  account  of  the  failure  of  conservative 
methods  and  the  case  is  growing  progressively  worse  in  spite  of  good 
drainage,  the  operation  is  performed  as  rapidly  as  possible  in  order  to 
diminish  the  shock  due  to  a  prolonged  operation. 

The  technique  is  the  same  as  that  described  under  excision  and  ar- 
throdesis when  the  tibia  and  femur  are  sawed  across.  The  diseased 
cavities  in  the  bone  should  be  removed  with  a  chisel  or  an  osteotome, 
cutting  them  out  wholly  in  the  healthy  bone.  There  will  be  just  as  good 
repair  and  less  shortening  by  this  method.  Before  placing  the  bones  in 
apposition  to  obtain  ankylosis,  small  holes  should  be  drilled  from  the 
anterior  or  lateral  surface  of  each  bone  to  the  cavities  chiselled  out  if  they 
are  deep.  This  will  insure  good  drainage.  Drains  should  be  used  in  all 
suppurative  conditions.  The  joint  should  be  immobilized  after  opera- 
tions on  the  knee  joint  or  its  vicinity. 

98a.  Methods  and  Principles  of  Drainage  in  Acute  Non-tubercular 
Suppurative  Joint  Disease.  Knee,  femur,  tibia. — A  small  suppurative 
focus  without  virulence  or  active  constitutional  disturbance  should  be 
drained  by  a  suitable  incision  wiped  out  with  gauze,  a  tube  placed  to 
its  deepest  part  and  the  soft  tissues  gaped  with  gauze. 


OPERATION  IN  SUPPURATIVE  CONDITIONS  89 

When  there  is  a  great  deal  of  constitutional  disturbance  drainage  and 
counter  drainage  should  always  be  the  rule.  If  the  bone  is  involved  this 
should  be  opened  and  counter  opened  as  shown  in  figure  66.  The  pus 
cavities  in  the  soft  tissues  should  be  wiped  out.  No  extensive  bone 
operation  should  be  done  otherwise.  The  bone  should  be  drained  with 
tubes  to  the  remote  portions  and  the  muscle,  fat  and  skin  gaped  by 
gauze.  The  operation  is  done  quickly  and  should  not  be  prolonged, 
but  efficient  drainage  and  counter  drainage  should  be  established  un- 
hesitatingly. It  is  rarely  necessary  to  do  more  at  this  time.  If  there 
is  a  marked  sequestra  formation  this  should  be  removed,  but  this 
had  better  not  be  done  at  the  time  of  instituting  drainage  when 
the  patient  is  nearly  exhausted  from  an  acute  process.  Any  future 
operation  made  necessary  should  give  good  drainage  and  the  removal 
of  the  sequestra  if  present  and  separated. 

Any  extensive  non-tubercular  suppurating  bone  disease  about  the 
knee,  tibia  or  femur  shaft  should  be  drained  by  two  long  lateral  incisions. 
If  the  patient  is  very  ill  and  the  bone  abscess  not  readily  located,  long 
incisions  with  large  drill  holes  alternating  in  the  bone  should  be  made 
(figure  66).  This  should  be  done  very  rapidly  and  good  drainage  estab- 
lished. 

In  any  chronic  suppurating  process  the  pockets  in  the  tissues  should  be 
well  opened  and  wiped  out  and  the  diseased  bone  well  drained  and 
counterdrained.  Large  incisions  should  be  made  with  tubes  to  all  de- 
pendent parts  and  large  gauze  pads  used,  gaping  the  wounds  for  at 
least  ten  days  and  then  the  tubes  and  wicks  shortened.  This  method 
of  treatment  is  usually  very  successful.  It  does  not  necessitate  the 
constant  reapplication  of  drains,  so  discomforting  to  the  patient.  Ir- 
rigations should  not  be  used  in  the  after  treatment  unless  the  Carrell- 
Dakin  method  is  used.  The  gauze  should  be  placed  around  rather 
than  over  the  wounds.  The  knee  should  be  immobilized  after  opera- 
tions on  the  joint  or  its  vicinity. 


PART  III— FOOT  AND  ANKLE 


CHAPTER  I 

OPERATION   FOR   DEFORMITIES 

99.  Manipulating  the  Foot. — The  patient  is  anaesthetized.  Usually  in 
manipulating  the  foot,  the  patient  lies  on  his  back,  the  foot  is 
flexed  and  extended,  adducted,  abducted  or  pronated  and  supinated. 
Dr.  Bradford  has  suggested  a  very  convenient  method  of  manipu- 
lating the  foot.  The  patient  lies 
on  his  abdomen  (see  figure  169), 
with  the  knee  flexed.  The  table 
should  be  low;  if  not  the  opera- 
tor may  stand  on  a  box  or  stool ; 
a  pillow  is  placed  under  the 
knee.  One  or  two  assistants 
hold  the  leg  above  the  ankle, 
the  operator  grasps  the  ball  of 
the  foot  in  both  hands.  This 
method  is  especially  effective  as 
the  operator's  weight  is  above 
the  foot,  adding  many  pounds 
to  the  strength  of  his  hands. 

The  power  of  the  hands  Or  foot    FlG- 121.— Thomas  wrench  applied  to  the  scaph- 
oid and  metatarsus. 

wrench    is.  applied    more 

directly  to  the  joints  of 

the  foot  without  motion 

of  the  leg.    The  peronei 

be  stretched,  the 

anticus,  and  pos- 

and    the   tendo 


should 
tibialis 
ticus 
Achilles;     the     terminal 

Fig.  122.— Thomas  wrench  applied  to  force  the  front    phalanges      of      the      toes 

of  the  foot  down  or  up.  flexed,  then  the  proximal 

phalanges,  then  the  metatarsophalangeal  joints  flexed  and  extended  with 
the  foot  at  first  in  dorsal  flexion  and  later  with  the  foot  in  equinus.  The 
operator  assures  himself  that  the  motions  of  all  the  toes  and  the  foot 
joints  are  normal.  The  foot  is  stretched  with  the  hand  or  with  one  of 
the  foot  wrenches. 

100.  Manipulation  of  the  Foot  by  Means  of  Apparatus. — When  it 
is  necessary  to  correct  deformities  of  the  foot,  and  do  a  tenotomy  of  the 

91 


92 


TECHNIQUE  OF  OPERATIONS 


Thomas  wrench  to  correct  equinus. 


ally  increas- 
ing manner 
until  consid- 
erable force 
is  applied 
and  then  re- 
laxing until 
very  slight 
force  is  used 
and  finally 
relaxing  en- 
tirely. In 
this  manner 
a     rhythmic 


tendo  Achilles,  the  ten- 
otomy of  the  tendo 
Achilles  should  be  per- 
formed last.  Stretch- 
ing of  the  foot  is  best 
performed  with  the 
tendo  Achilles  intact. 
The  joint  is  gently 
stretched  and  relaxed, 
the  operator  applying 
force  gently  in  a  gradu- 


Fig.  125. 


Fig.  124. — The  Thomas  wrench,  used  in  manipulating  the  foot  before 
or  after  operations  on  the  foot.  The  wrench  is  nickeled  and  may  be 
sterilized.  The  jaws  that  hold  the  foot  are  removable  and  vary  in 
shapes  (see  figure  125)  to  fit  the  deformities;  and  to  fit  children's  or 
adults'  feet.  By  stretching  with  it  a  much  less  extensive  operation  is 
necessary. 

stretching  is 
kept  up.  No 
rough  or  forci- 
ble motion  with- 
out a  gradually 
increasing  and 
gradually  de- 
creasing force 
should  be  em- 
ployed. A  joint 
that  at  first  will 
seem  almost  im- 
possible  to 
move  will  often 
give  way  and 
straighten. 
When  the  front 
of  the  foot  and 
other  deformi- 
ties are  satis- 
factorily      cor- 


-Thomas  wrench,  actual  size  of  head  of  wrench;  jaws  fit  in 
the  squares. 


OPERATION  FOR  DEFORMITIES 


93 


94 


TECHNIQUE  OF  OPERATIONS 


Fig.  130. — Thomas  wrench  applied  to  the  metatarsus 
and  cuboid. 


Fig.  131. — Thomas  wrench  applied  to  the  astragalus 
and  cuboid. 


Fig.  132. — Thomas  wrench  to  limber  the  tarsus  at  the 
cuboid. 


c_z_ 


Fig.  133. — Thomas  wrench  applied  to  correct  varus. 


OPERATION  FOR  DEFORMITIES 


95 


CZ 


Fig.    134. — Thomas    wrench 


rected,     then    the    tendo 

Achilles    may  be    tenoto- 

mized  if  necessary. 

101.  Manipulating    the 

Foot    by   Means   of    the 

Thomas  Wrench. — A  very 

convenient      wrench      for 

manipulating   the   foot  is 

known    as     the    Thomas 

Wrench,     represented     in 

figure   124.    It  is  a  large 

monkey     wrench     fifteen 

inches  long.     The  wrench   a£edd  t0  the  scaphoid  and 

has  two  arms  which  grasp 

the  foot.    These  arms  are  six  inches  long.    The 

exact  length  and  dimension  of  these  jaws  are  out- 
lined in  figures  124  to  129.    They  vary  in  size  and 

contour  and  may  be  applied  to  the  wrench  in  order 

to  fit  a  large  or  a  small  foot.    In  the  use  of  force  to 

correct   deformity,   slight   pressure    is  applied   by 

means  of  the  wrench  and  then  the  force  relaxed. 

Slight  pressure  is  again  brought  to  bear  by  means  of 

the  wrench  and  then  relaxed.    With  a  rhythmic  ap- 
plication of  force,  and  then  relaxation,  the  blood  en- 
ters the  stretch- 
ing tissues  and       Fig.  135  —  Dr. Brad- 
there  is  less  dan-  *°rd's  ?lub  foot  wrench. 

~      ,         .  By  using  this    wrench 

ger     Of     tearing  before  0r   after  opera- 

them  at  any  one  ting  on  the  foot  a  much 

point.       Consid-  j^s  extensive  operation 

-     ,    ,          j.  ls  necessary.    1  he  mid- 

erable  force  die  section  slides,  ad- 
may  be  applied  Justing  itself  to  the  size 
•         .  i    •  of  the  foot. 

in    this    way, 

with  less  swelling  after  a  forcible 

manipulation  than  if  the  parts  are 

handled  roughly.    The  stretching  of 

a  deformity  should  be  slow  and  not 

violent.    In    applying    the   various 

Fig.  137.— Single  mechanical  foot  stretchers,  an  ex- 

t"f^S,^r  treme  deformity  which  gives  way 

very  little  at  first  will  often  yield 

■i  entirely  if  the  operator  is  patient. 

Figures  121  to  134  represent  the 

Fig.  138.— Removable  end  of         many    methods    of    applying    the 

tZZSt  -!*  a"  in         Th°™s  wrench  to  the  foot. 

an  ordinary  instrument  sterilizer.  After      any     foot      operation     the 


Fig.  136. —  The 
great  toe  metatarsal 
hold  used  for  the  left 
foot,  the  other  for 
the  right;  this  one  is 
detached,  the  other 
is  in  place.  (See  fig- 
ure 135). 


c 


96  TECHNIQUE  OF  OPERATIONS 

wrench  will  help  complete  the  correction  of  the  deformity  and  make 
more  extensive  operations  unnecessary.    These  wrenches  are  especially 


Fig.  139. — Dr.  Bradford's  club  foot  wrench  applied,  to  raise 
the  cuboid  and  abduct  the  foot. 

useful  in  obtaining  the  normal  range  of  motion  in  the  foot  before  other 
operations. 

102.  Manipulation  of  the  Foot  by  Means  of  the  Bradford  Wrench.— 
Figures  145  to  150  represent  one  of  Dr.  Bradford's  club  foot  wrenches 


Fig.    140. — Dr.  Bradford's  club  foot  wrench,  external 
view  from  above. 

to  correct  deformity  in  the  foot  and  ankle.  While  designed  to  correct 
club  foot  it  readily  adapts  itself  to  the  correction  of  the  other  foot  de- 
formities and  to  limber  up  the  joints  of  the  ankle  and  foot. 


OPERATION  FOR  DEFORMITIES 


97 


Fig.  141. — Dr.  Bradford's  club  foot  wrench,   external 
view  from  below. 


Fig.  142. — Dr.  Bradford's  club  foot  wrench,  internal 
plantar  view. 


Fig.  143. — Dr.  Bradford's  club  foot  wrench,  internal  view 
from  above. 


98 


TECHNIQUE  OF  OPERATIONS 


Pig.    144. — Dr.    Bradford's    club    foot 
wrench. 


Fig.  145. — Another  of  Dr.  Bradford's  club  foot  wrenches  taken  apart;  by  using  this  wrench 
before  or  after  operating,  a  much  less  extensive  operation  is  necessary.  A  is  applied  to 
the  bar  C  at  A.  B  is  applied  to  the  bar  C  at  B.  The  bar  C  is  first  applied  to  the  hole  C. 
The  hook  D  is  applied  to  the  hole  D.     (See  illustrations  146  to  150.) 


OPERATION  FOR  DEFORMITIES 


99 


Pig.  147. — Dr.  Bradford's  other  club  foot  wrench 
applied  to  the  foot.    External  view. 


Fig.  146. — Dr.  Bradford's  other 
club  foot  wrench  applied  to  the  foot. 
Plantar  view. 


Fig. 


148. — Dr.  Bradford's  other  club  foot  wrench  ap- 
plied to  the  foot.     Internal  and  plantar  view. 


They  will  also  be 
useful  in  increasing 
the  flexibility  in  the 
joints  of  the  foot 
and  ankle. 

Another  wrench 
of  Dr.  Bradford's 
(see  figures  135  to 
144)  is  used  to  cor- 
rect the  deformities 
of  the  foot.     This 

wrench  is  useful  to  limber  up  the  foot  and  help  correct  the  ankle  and 

foot  deformities. 

103.  Manipulation  of  the  Foot  by  Means  of  Dr.  Davis  Wire  Foot 
Wrench. — Dr.  Gwilym  Davis'  wire  foot  wrench  (see  figures  151-155), 
is  used  to  correct  deformities  of  the  foot. 

104.  Operation  for  Talipes  Varus,  and  Equino  Varus,  Club  Foot. — 
A  varus  or  equino  varus  (see  figures  160-161)  may  be  slight  or  extreme. 


Fig.  149. — Dr.  Bradford's  other  club  foot  wrench  applied  to  the 
foot.    Dorsal  view. 


100 


TECHNIQUE  OF  OPERATIONS 


Fig.    151.— Dr.    Davis' 

wire  foot  stretcher  applied, 
plantar  view.  It  consists 
of  a  heavy  inflexible  iron 
wire  and  two  webbing 
straps.  Dimensions  of  the 
wrench.  Length  =  19}/£ 
inches.  Width  =  5  inches. 
Diameter  of  wire  =  3/s 
inches.  Cross  piece  length 
=  7J^  inches.  Distance 
between  ends  of  cross  piece 
=  5  inches. 


Fig.  150. — Dr.  Bradford's  other  club  foot  wrench  ap- 
plied to  the  foot.    Dorsal  view  with  force  applied. 

It  may  be  due  to  over-strong  tibialis  posticus  or 

anticus  and  long  flexor  of  the  toe  tendons  with 

weak   peronei;  or   it   may    be   due  to    relaxed 

peronei  with  not  over-strong  muscles  on  the  in- 
side of  the  foot,  or  the  muscle  may  be  paralyzed 

and  the  deformity  due  to  lack  of  foot  balance,  or 

to  uneven  bony  overgrowth,  or  lack  of  growth. 
In  some  cases  the  deformity  is  acquired  at  the 

time  when  the  patient  begins  to  recover  from  a 

paralysis.     After  operation  sometimes  the  weak 

muscles  are  made  as  strong  as  ever  if  the  foot 

is  overcorrected,  and  put  in  a  position  of  valgus,  followed  by  muscle 

training. 

When  the  cor- 
rection of  a  varus 
or  e  q  u  i  n  o-varus 
cannot  be  main- 
tained after  proper 
relaxation  of  the 
contracted  tissues 
and  training  of  the 
peroneii,  it  may  be 
necessary  to  trans- 
plant the  tibialis 
anticus  or  the  long 
toe  extensors  to 
the  middle  of  the 
midtarsus  region. 
This  often  is  suf- 
ficient    in     slight 


Fig.  152. — Dr.  Davis'  wire  foot  stretcher 
applied.     Internal  view. 


Fig.  153.— Doctor 
Davis'  wire  foot 
stretcher  applied. 
Dorsal   view. 


OPERATION  FOR  DEFORMITIES 


101 


Fig.     154.— Dr.     Davis' 


varus  cases  where  the  lateral  stability  of  the  foot  is  otherwise  good. 
In  a  case  where  the  posterior  tibial  muscles  and  the  long  flexors  of  the 
toes  are  extremely  strong,  the  anterior  tibial  muscle  must  be  put  fur- 
ther to  the  outer  side  or  one  of  the  strong  muscles 
transplanted  forward  and  outward  to  balance  it. 

Before  transplanting,  the  normal  motion  of  the 
joint  must  be  restored.  Any  tendency  of  equinus 
must  be  overcome  by  stretching  and  by  a  teno- 
tomy. No  transplantation  should  be  performed 
unless  the  action  of  the  ankle  is  free  and  the  de- 
formities overcome.  Where  the  long  flexor  of  the 
toes  is  extremely  good,  this  muscle  may  be 
transplanted  forward  to  restore  the  balance  of 
the  foot.  (For  a  description  of  the  transplanta- 
tion of  the  long  flexor  of  the  toe  forward,  or  of 
the  tibialis  posticus  forward,  the  reader  is  re- 
ferred to  subsequent  pages.) 

In  transplanting  the  long  toe  flexor,  or  the 
tibialis  posticus  forward,  it  should  be  remembered  ™ire  fo°t  stretcher  applied. 

.     .  ,  .!        •    •    ,     i         ...  ,    External  view. 

not  to  weaken  the  joint    by  incisions  around 

the  malleoli.     The  tibialis  posticus  lies  anterior  to  the  flexor  longus 

digitorum,  but  these  tendons  are  best  dif- 
ferentiated by  pulling  on  the  tendon,  and 
noticing  the  flexion  of  the  toes  in  the  case  of 
the  long  flexor.  The  tibialis  posticus  lies 
anterior,  and  the  flexor  longus  digitorum 
Fig.  155.— Dr.  Davis'  wire  nex+     the   posterior   tibial    artery   and   the 

foot    stretcher    applied    to    the  j      •  mi  i  • 

patient  in  Dr.  Bradford's  posi-  nerves  are  posterior.      There  are  also  two 
tion,  for  manipulation  of  the  small  plantar  cutaneous  nerves. 
foot-  In  cases  in  which  the   varus  is  extreme 

and  due  to  position  rather  than  to  muscle  pull,  especially  when  the 
muscles  are  weak, 
after  correcting  the 
deformity  by  man- 
ipulation and  teno- 
tomies, silk  liga- 
ments may  be  used 
for  one  or  two  years 
to  maintain  stabil- 
ity of  the  ankle. 
In     children    over 

seven  Or  eight  years  Fig.  156. — Plaster  split  at  the  sides  with  plaster  rope  flattened 
Old,    and    in    adults  to  prevent  rotation  of  the  leg.     Side  view. 

where  the  ankle  is  very  much  relaxed  (the  so-called  "dangle  foot")  an 
astragalectomy  with  displacement  of  the  foot  backward  is  advisable. 
This  will  give  good  lateral  stability  without  a  stiff  joint.   Where  silk  liga- 


102 


TECHNIQUE  OF  OPERATIONS 


ments  are  used  as  a  temporary  means  of  retaining  the  foot,  Dr.  Bradford's 
operation  for  subcutaneous  silk  ligament  is  simple  (see  section  173) 
and  preferable  to  the  method  by  open  incision. 

An  open  or  closed  operation,  cutting  all  resistant  tissues  on  the  inner 
side  of  the  foot  called  the  Phelps  operation,  should  not  be  done.  There 
are  much  better  and  less  mutilating  operations  to  correct  varus  or 
equino  varus. 

105.  Operation  on  the  bone  for  Extreme  Varus,  or  Equino  Varus  (club 
foot  operation)  Congenital  or  Acquired. — The  following  operations  are 


Fig. 


157. — End  view  of 
figure  156. 


Fig.  158. — Method  of  spreading  a  wet  three  inch  gauze 
bandage  and  tying  a  split  plaster. 


indicated  in  congenital  club  foot  as  well  as  in  the  infantile  and  acquired 
forms,  depending  on  the  degree  of  deformity.     When  it  is  extreme,  it 


Fig.  160. — Equino  varus.    Club 
foot.    Plantar  view. 


k 


Fig.  159. — Equinus. 

is  often  necessary  to  take 

a  small  wedge  from  the 

forward    end   of   the   os- 

calcis  and  sometimes  from 

the  astragalus  to  obtain  complete  over-correction  of 

the  deformity. 

In  the  paralytic  club  foot  it  is  not  necessary  to 
overcorrect  to  the  same  extent  that  it  is  necessary 
in  the  congenital,  but  a  slight  over-correction  should 
always  be  made.  If  the  deformity  is  extreme,  how- 
ever, the  over-correction  should  be  proportionate.  fkj.  i6i.— Equino 

When  after  manipulation  and  tenotomy  of  the  varus.  Club  foot, 
plantar  fascia  a  complete  over-correction  is  not  ob-  atera  view* 
tained,  without  force,  a  small  wedge  of  bone  is  removed  from  the 
astragalus  and  os-calcis  (see  shaded  portion,  figure  163).  This  is 
done  through  an  incision  anterior  to  the  tip  of  the  fibula  and  ex- 
tending towards  the  prominence  at  the  base  of  the  fifth  metatarsal. 
The  incision  is  carried  down  to  the  bone,  the  tendons  and  muscles 


OPERATION  FOR  DEFORMITIES 


103 


retracted,  exposing  the  prominent  portion  of  the  astragalus.  A  small 
wedge  is  removed  from  this  bone  in  such  a  way  that  the  closing  of  the 
gap  will  allow  the  foot  to  dorsally  flex.  The  osteotome  should  enter 
the  bone  some  distance  from  the  tibia  in  order  that  the  callus  from  bone 
healing  will  not  interfere  with  the  motion  of  the  ankle  joint.  See  figure 
494.  Should  the  eversion  be  difficult  to  obtain,  a  small  wedge  is  taken 
out  of  the  forward  end  of  the  os-calcis,  allowing  the  foot  to  evert.      A 


Fig.  162. — Calcaneous. 


Fig.  163. — Shaded  portion  of  bone  must 
sometimes  be  removed  in  extreme  club  foot 
deformity.  The  size  of  the  wedge  and  its 
shape  will  vary  with  the  deformity. 


small  wedge  of  bone  should  be  removed  and  then  more  as  the  case  re- 
quires, though  an  operator  familiar  with  bone  operations  for  club  foot 
may  often  judge  the  right  amount  from  the  start.  Where  much  tilting 
of  the  os-calcis  accompanies  an  equino  varus,  Dr.  Ober  has  suggested  the 
loosening  of  the  ligaments  from  the  internal  malleolus  allowing  the  over- 
correction of  the  tilt  of  the  os-calcis  during  the  correction  of  the  deform- 


Fig.  164. — Incision  two  inches  above 
the  tip  of  the  malleolus  curving  down- 
ward and  forward. 


Fig.  165. — The  regular  line  marks  the 
malleolus,  the  irregular  line  indicates  the 
raised  periosteum.    The  tendon  is  below. 


ity  at  the  front  of  the  foot.      This  latter  operation  is  often  sufficient 
without  removing  bone. 

106.  Operation  for  Equino  Varus,  Congenital  or  Acquired.  Reliev- 
ing the  Internal  Ligamentous  Attachments  when  the  Os-calcis  is  Tilted 
or  Rotated  in  and  under.  Dr.  Ober's  Operation. — The  foot  is  pre- 
pared in  the  usual  way,  the  patient  lies  on  his  back,  a  sand  bag  is  placed 
under  the  foot,  the  operator  stands  on  the  outer  side  of  the  right  foot, 


104 


TECHNIQUE  OF  OPERATIONS 


an  assistant  holds  the  ball  of  the   foot   while  the  incision  is  being 
made. 

Before  making  an  incision,  the  foot  is  manipulated  and  stretched  as 
described  under  Manipulation.  An  incision  is  made  on  the  inner  side 
of  the  tibia  from  a  point  V/i  t°  2  inches  above  the  internal  malleolus, 
curving  downward  and  forward  to  the  scaphoid  (see  figure  164).  The 
[incision  is  curved  slightly;  it  is  carried  down  to  the  bone,  its  edges  re- 
•  tracted  exposing  the  periosteum  over  the  internal  malleolus  (see  figure 
165).  This  periosteum  is  incised  across  one  inch  above  its  tip,  and  on 
either  side  of  the  tip,  the  periosteum  is  raised  in  one  piece  from  the  flat 
surface  of  the  bone,  the  irregular  line  marks  the  raised  periosteum 
(figure  166),  the  anterior  and  posterior  surfaces  continuously  with  the 


Fig.  166. — The  osteotome  raises  the 
periosteum  and  ligaments  subperiostially 
extending  anteriorly. 


Fig.  167. — The  osteotome  raises  the  peri- 
osteum and  ligaments  subperiosteally  below 
the  malleolus. 


ligaments,  and  on  either  side  of  the  malleolus  (see  figures  167  to  170). 
An  osteotome  is  used  to  lift  the  attachment  of  the  ligaments  free  from  the 
malleolus  continuously  with  the  periosteum.  The  lifting  of  the  perios- 
teum and  ligaments  is  continued  to  the  ligaments  of  the  astragalus  and 
os-calcis,  the  astragalus  and  scaphoid  allowing  the  foot  to  swing  freely 
outward.  The  raised  periosteum  on  the  tibia  is  drawn  downward  as 
the  deformity  is  corrected.  The  internal  lateral  ligament  is  freed  to- 
gether with  the  anterior  ligament,  the  dorsal  astragaloscaphoid  liga- 
ment, and  the  attachment  at  the  scaphoid  tubercle.  The  foot  is  then 
manipulated  and  the  amount  of  overcorrection  estimated.  It  is  suffi- 
cient if  the  tilt  in  the  os-calcis  is  overcorrected  and  the  cuboid  goes  well 
up  into  place,  and  if  the  dorsal  motion  to  the  foot  and  eversion  of  the 
front  part  of  the  foot  is  easy  to  obtain.  The  tendo  Achilles  is  ten- 
otomized  last  (see  previous  chapter  on  Tenotomy  of  the  Tendo  Achilles). 
This  tenotomy  is  done  last  as  it  is  necessary  for  it  to  hold  the  os-calcis 
during  the  correction  of  the  deformity.  If  sufficient  correction  is  not 
obtained  by  freeing  the  ligaments  the  operator  will  use  the  Thomas 


OPERATION  FOR  DEFORMITIES 


105 


wrench  (see  figure  124),  or  the  Bradford  wrench  (see  figures  135  and  145) 
before  and  after  cutting  the  tendo  Achilles;  the  periosteum  is  not  sutured. 
The  deep  tissues  are  brought  together  over  the  bone  by  interrupted  chro- 
mic catgut  sutures  number  00,  the  subcutaneous  tissues  with  interrupted 

chromic  catgut  sutures  number  00, 
and  the  skin  with  continuous  chromic 
catgut  sutures  number  00.    A  very 


Fig.  170.— Plantar 
view.  The  irregular  line 
indicates  the  tissues 
raised  subperiosteally 
from  the  tarsus. 


Fig.  169. — Lateral  view.  "  The  ir- 
Fig.    168. — The    osteotome    extending  regular    line    indicates    the    tissues 

backward  subperiosteally  under  the  liga-  raised  subperiosteally  from  the  tar- 

ments  and  tendons.  sus. 

small  amount 
of  gauze  is 
placed  over 
the  wound, 
only  about 
four  thin  lay- 
ers, extending 
one-half  inch 
either  side 
and  beyond 
the    ends    of 

the  incision  in  order  to  have  no 
lumps.  Sterile  sheet  wadding  is 
next  applied  to  fit  the  foot  snugly 
so  that  the  outlines  of  the  leg  and 
foot  are  shapely  and  the  amount  of 
correction  easily  estimated.  A  plas- 
ter  of  Paris  bandage  is  applied  from 

the  toes  to  the  groin  With  the  knee    foot  cuff  of  the  plaster  bandage  with  only 

bent.     (For  details  of  this  plaster,  tw.°  heel  turns  to  hold  it  on.   CD,  Leg  and 

11         \  thigh  cuff.    When  these  cuffs  have  har- 

See  DeiOW.;  ...  .         dened  the  foot  is  held  over-corrected,  the 

It  will  be  noticed  in  this  Operation    plaster  then  is  completed  by  uniting  the 

that  the  operator  raises  the  perios-  two  cuffs- 

teum  from  the  inner  side  of  the  internal  malleolus,  a  strip  1  or  13^ 
inches  long,  2  inches  in  adults  and  as  broad  as  the  malleolus.  As  this 
is  raised  from  the  bone  with  an  osteotome,  it  is  lifted  continuously  with 


106 


TECHNIQUE  OF  OPERATIONS 


the  ligaments  and  periosteum  below  for  at  least  an  inch  below  the  tip 
of  the  malleolus.  The  periosteum  anteriorly  is  raised  from  the  tip  of 
the  malleolus  continuously  with  the  ligaments  and  periosteum  over  the 
bones  for  at  least  an  inch  forward  and  downward.  Posteriorly  the  same 
process  is  repeated,  the  osteotome  dipping  behind  the  tendon  sheath  and 
lifting  them  with  the  periosteum  below  them  (see  figures  1G9,  170). 

107.  Application  of  Plaster  for  Varus  or  Equino  Varus,  Club  Foot 
Plaster. — Some  care  is  necessary  in  applying  a  plaster  to  the  foot  for 

correction  of  bone  deformity;  a  liberal  amount  of 
well  fitting  sheet  wadding  is  applied  then.  About 
eight  layers  of  plaster  of  Paris  bandage  are  applied 
around  the  ball  of  the  foot  and  metatarsals,  two 
la3rers  only  around  the  heel  to  prevent  this  cuff  from 
slipping  off.  This  is  allowed  to  harden  while  the 
plaster  is  applied  to  the  thigh  and  leg  with  the  knee 
flexed  eighty  degrees.  When  these  two  portions  are 
hard,  the  patient  is  turned  over  on  his  abdomen  and 
a  pillow  is  placed  under  the  knee.  The  operator 
holds  the  foot  overcorrected  (see  figure  171),  while 
an  assistant  joins  the  two  portions  of  the  plaster, 
Fig.  172T—  After  In  this  way  there  is  no  cramping  of  the  toes  which 
operation  a  club  foot  are  held  flat  and  the  plaster  is  applied  to  the  de- 
should    be   held   in  formity  while  it  is  held  corrected.    If  the  operation 

plaster  well  abducted    .  ,  ,  P  .,,  ., 

dorsaiiy  flexed  and  has  been  thoroughly  done,  the  foot  will  easily  over- 
with  the  cuboid  ele-  correct  without  force.  Good  overcorrection  of  the 
deformity  is  a  sure  method  of  preventing  pressure 
sores  and  discomfort  from  the  plaster.  The  position  of  overcorrection 
of  the  foot  in  plaster  is  important.  A  vertical  line  through  the  mid- 
dle of  the  lower  leg  is  drawn  on  the  plaster.  This 
line  should  be  determined  by  an  imaginary  plane 
passed  through  the  femur  and  tibia.  The  foot  should 
be  abducted  fifty  degrees  from  this  plane.  It  should 
be  dorsaiiy  flexed  about  twenty-five  degrees,  the  cu- 
boid being  raised  more  than  the  rest  of  the  foot  (see 
figure  172). 

108.  The  After  Treatment  of  Equino  Varus.— The 
patient  should  wear  a  plaster  for  six  or  eight  weeks 
with  the  knee  flexed  forty-five  degrees  to  eighty  de- 
grees and  maintaining  extreme  overcorrection   (see 
figure  172).    At  the  end  of  this  time  a  lighter  plaster 
is  applied  with  the  knee  flexed  only  twenty  degrees. 
The    patient   is    allowed  to   walk   on    the    plaster. 
Wooden,  felt  or  plaster  wedges  are  applied  to  the  wedged     to     make 
sole  of  the  plaster  to  aid  in  locomotion.    When  walk-  talking  more  easy, 
ing  is  good,  a  wedged  shoe   (see  figure   173)   and   brace,  or  simply 
the  wedged  shoe  is  worn.    Exercises  for  all  the  muscles  become  part  of 


Fig.  173.— Wedged 
shoe.  When  an  over- 
corrected  position  is 
to  be  maintained,  the 
brace  is  bent,  the 
heel  of  the  shoe  is 
broadened      and 


OPERATION  FOR  DEFORMITIES  107 

the   after   treatment   with    manual    overstretching   of    the   deformity 
daily. 

109.  Methods  of  Obtaining  Stability  at  the  Ankle  and  Foot.  Opera- 
tion for  Valgus,  Equino  Valgus  and  Calcaneo  Valgus.  Flat  foot. — 
The  following  operation  is  also  used  for  congenital  and  acquired  flat 
foot. 

Equino  valgus,  calcaneo  valgus  and  flat  foot,  valgus  (figures  175, 
176). 

In  some  paralytic  and  congenital  valgus  deformities  the  tibialis 
anticus  and  tibialis  posticus,  and  long  flexors  of  the  toes  are  either 
paralyzed  or  very  much  weakened,  or  proportionally  weaker  than  their 
opponents.  In  some  cases  the  muscles  are  all  weak  and  the  deformity 
is  due  to  attitude  or  bony  growth.  In  these  conditions  the  peronei 
muscles  are  sometimes  found  very  strongly  contracted,  so  that  they 
seem  powerless.  To  restore  a  balance  of  the  foot,  first  the  deformities 
should  be  overcorrected  by  operation  unless  they  are  very  slight  and  the 
muscles  trained  and  given  the  best  possible  chance  to  develop  under 
orthopedic  treatment.  In  paralytic  cases  where  the  peronei  are  strong 
and  the  patient  cannot  raise  the  foot,  a  transplantation  of  the  peronei 
forward  is  often  advisable.  When  this  is  decided  upon  the  muscles  are 
transplanted  as  described  elsewhere  under  muscle  transplantation. 
The  position  of  insertion  of  the  tendon  will  depend  on  the  position  and 
strength  of  the  other  good  muscles.  In  extreme  valgus  the  internal 
cuneiform,  or  scaphoid,  may  be  selected  as  the  best  position  for  inser- 
tion; in  some  other  deformities  the  middle  or  outer  cuneiform.  Where 
there  is  good  lateral  stability  at  the  ankle,  the  tendon  should  be  put  in 
about  the  middle  of  the  foot.  Where  there  is  a  marked  lack  of  stability 
at  the  ankle  joint  an  astragalectomy  with  displacement  of  the  foot 
backward  gives  an  extremely  good  foot  without  stiffening  the  ankle  and 
to  this  a  transplantation  of  the  peronei  forward  may  be  done  to  great 
advantage.  Where  the  extensors  of  the  toes  are  extremely  active,  and 
this  is  often  the  case  in  paralytic  cases  where  the  peronei  are  spared, 
there  is  often  a  marked  hammer  toe  due  to  the  con- 
tracture of  the  extensors  of  the  toes  which  are 
stretched  upward  as  they  are  constantly  used  in  rais- 
ing the  foot.  Where  there  is  a  hammer  toe,  it  is  well 
in  the  case  of  the  great  toe  to  transplant  the  tendon 
of  the  great  toe  into  the  head  of  the  metatarsal,  and 
also  to  use  the  other  long  extensor  of  the  toes  either 
in  the  same  way,  or  better  still  to  attach  them- to  the 
tarsus  and  cut  them  away  below. 

110.  Extreme  Valgus,  Calcaneo  Valgus,  and  Equino  FlG\  }74 •-   Valsus 

■xt   ,  Tj.,,  ,       ,      ,  t  with  hammer  toes. 

Valgus. — It  there  are  no  muscles  to  transplant  any  one 
of  the  above  methods  of  correction  may  be  selected.    For  a  very  hopeless 
flail  ankle  an  astragalectomy  and  displacement  of  the  foot  backward  is 
the  operation  of  choice.    When  it  is  possible  to  transplant  a  muscle  to  a 


108  TECHNIQUE  OF  OPERATIONS 

position  of  greater  usefulness  it  should  be  done  in  addition  to  correcting 
the  valgus. 

When  a  valgus  has  existed  for  a  long  time  uncorrected  and  there  is 
often  much  bony  change  similar  to  that  seen  in  congenital  valgus  cases, 
a  wedge  of  bone  may  be  removed  from  the  scaphoid  and  adjoining  bones 
further  outward,  the  closing  of  the  gap  correcting  the  abducted  and 
flattened  foot.  When  the  os-calcis  tilts  markedly,  the 
external  ligaments  may  be  loosened  subperiostically 
from  the  external  malleolus,  and  from  the  os-calcis 
subperiosteal^  as  described  below,  allowing  the  bone 
to  swing  under  the  astragalus  and  tibia. 

The  correction  of  valgus  is  usually  possible  by 
manipulation  with  the  hands  or  by  one  of  the  wrenches 
described  for  manipulation  of  the  foot.  The  foot 
should  be  made  limber  in  all  normal  directions  and 
the  valgus  overcome. 
Fig.  175. —  Valgus,  When  the  condition  is  extreme,  and  has  existed 
since  the  onset  of  a  paralysis,  the  correction  should 
be  made  by  operation  and  the  tibial  muscles  allowed  to  regain  strength. 
When  this  does  not  occur  or  if  they  are  found  to  be  definitely  paralyzed 
or  extremely  weak,  after  attempts  to  train  and  develop  them,  a  trans- 
plantation of  other  muscles  forward  may  be  made.  The  correction  of 
valgus  due  to  deformity  of  the  bone  is  best  done  by  removing  a  wedge 
from  the  scaphoid,  or  if  the  ankle  is  flail,  by  an  astragalectomy,  or  both 
tibialis  tendons  may  be  inserted  into  grooves  in  the  tibia  anteriorly 
and  posteriorly  and  buried  there  to  act  as  internal  ligaments  prevent- 
ing valgus  (see  Artificial  Ligaments). 

111.  Bone  Operation  for  Valgus  or  Equino  Valgus  or  Calcaneo 
Valgus. — The  patient  lies  on  his  back,  the  knee  outwardly  rotated,  a 
rubber  bandage  is  applied  to  evasculate  the  foot  and 
leg  and  a  tourniquet  is  applied  below  the  knee,  the 
foot  resting  on  a  sand  bag.  The  operator  stands  on 
the  side  of  the  leg  to  be  operated  on. 

An  incision  is  made  one-half  inch  anterior  and  one- 
half  inch  below  the  internal  malleolus  extending  for- 
ward to  the  first  metatarsal.  The  incision  is  carried 
down  to  the  bone,  the  tissues  dissected  up,  retracted 
in  one  layer  exposing  the  scaphoid;  the  tibialis  tendons  Fig.  176.  —  Valgus, 
are  retracted  and  carefully  protected  from  injury.  A  latera  view, 
wedge  of  bone  is  removed  from  the  scaphoid  and  the  adjoining  bones,  if 
necessary,  to  allow  the  foot  to  swing  in,  as  the  gap  closes.  The  perios- 
teum is  tough  at  the  inner  side  of  the  foot,  making  it  easy  to  place 
sutures  to  hold  the  bones  together.  The  deep  and  superficial  tis- 
sues are  brought  together  with  interrupted  chromic  catgut  sutures 
number  00,  the  skin  with  continuous  chromic  catgut  sutures  num- 
ber 00. 


OPERATION  FOR  DEFORMITIES  109 

If  the  deformity  is  largely  clue  to  a  tilted  os-calcis,  the  following 
operation  will  be  useful. 

112.  Operation  for  Valgus  with  Marked  Tilting  of  the  Os-calcis. — 

The  patient  lies  on  his  back,  the  operator  stands  on  the  side  of  the  leg 
to  be  operated  on,  a  rubber  bandage  and  tourniquet  are  applied. 

A  curved  incision,  two  and  one-half  inches  long  is  made  one  inch 
above  the  tip  of  the  external  malleolus,  extending  forward  and  down- 
ward to  the  cuboid.  The  skin  and  subcutaneous  tissues  are  dissected 
up  exposing  the  malleolus.  An  osteotome  is  used  to  free  its  ligaments 
subperiosteally  from  the  outer,  inner,  posterior  and  anterior  surface, 
also  the  attachments  of  these  ligaments  to  the  os-calcis  and  astragalus; 
all  are  freed  subperiosteally.  This  will  usually  allow  the  foot  and 
os-calcis  to  be  brought  into  position  either  manually  or  by  wrenches. 
If  not  the  astragalo  calcaneous  ligament  is  separated  subperiosteally  by 
means  of  an  osteotome  inserted  between  these  bones.  The  attachment 
here  is  very  extensive,  the  separation  should  be  done  with  care  in  order 
to  cut  all  the  fibers,  the  operator  feeling  for  each  soft  attachment  and 
cutting  it,  injuring  the  bone  as  little  as  possible.  The  foot  wrenches 
(figures  123  to  155)  will  aid  the  operator  to  complete  the  overcorrec- 
tion. If  sufficient  overcorrection  cannot  be  obtained  by  this  process, 
the  operator  should  remove  a  wedge  of  bone  as  described  for  valgus. 

113.  Plaster  of  Paris  Bandage  for  Valgus. — A  plaster  of  Paris  band- 
age is  applied  from  the  toes  to  the  groin  with  the  knee  bent,  as  follows : 
a  liberal  quantity  of  well  fitting  sheet  wadding  is  applied  to  the  foot  and 
leg,  an  extra  amount  being  placed  on  the  heel.  Eight  turns  of  plaster 
bandage  are  placed  over  the  ball  of  the  foot  and  around  the  metatarsals 
in  front.  Only  one  or  two  turns  are  made  around  the  heel  to  hold  the 
cuff  on.  The  cuff  is  allowed  to  harden  while  the  plaster  is  put  on  from 
above  the  ankle  to  the  groin  with  the  knee  bent.  When  this  has  har- 
dened the  patient  is  turned  over  on  his  abdomen,  the  knee  rests  on  a 
cushion,  the  operator  holds  the  ball  of  the  foot  in  a  dorsal  position  and 
adducts  it,  correcting  the  deformity  while  the  plaster  is  completed  be- 
tween the  foot  cuff  and  the  leg.  The  heel  should  not  be  allowed  to  be 
dented  or  to  rest  on  the  table  or  bed.  After  an  extensive  operation, 
the  patient  is  kept  quiet  for  three  weeks.  After  that  he  is  allowed  to 
sit  in  a  chair.  At  the  end  of  the  fourth  week  he  walks  on  the  other  foot, 
using  crutches.  Weight-bearing  is  allowed  in  the  eighth  week,  depend- 
ing on  the  case;  always  with  the  plaster  at  first.  After  the  eighth  week 
the  knee  may  be  flexed  twenty  degrees  only. 

In  infantile  paralysis,  as  in  congenital  valgus,  overcorrection  is  made 
with  the  feet  in  marked  adduction  so  that  they  interfere  in  walking. 
This  is  maintained  at  least  six  months.  Walking  is  made  possible  by 
wooden  or  plaster  wedges  under  the  sole  of  the  plaster. 

When  a  transplantation  is  done  at  the  same  time,  the  rules  laid  down 
for  transplantation  must  be  observed;  when  tenotomies  alone,  or 
mechanical  wrenching,  these  conditions  will  govern  the  after  treatment. 


110  TECHNIQUE  OF  OPERATIONS 

Rules  for  after  treatment  in  these  cases  are  laid  down  under  transplan- 
tation, tenotomy,  use  of  foot  wrenches,  etc. 

This  arrangement  of  the  plaster  is  important  in  most  operations 
on  the  foot.  A  window  is  cut  in  the  plaster  over  the  point  of  operation 
to  allow  inspection  of  the  incision.  The  plaster  should  be  split  on 
both  sides  so  that  it  may  be  loosened  or  removed.  The  patient  is 
allowed  to  walk  on  the  foot  at  the  end  of  six  weeks  with  the  plaster  on. 
When  the  patient  is  able  to  walk  easily  with  the  plaster  it  may  be  re- 
moved for  a  few  steps  two  or  three  times  a  day  until  walking  is  easy 
without  the  plaster.  .  When  this  has  been  accomplished  the  plaster  is 
omitted.    The  leg  and  foot  should  be  exercised  and  the  muscles  trained. 

114.  Operation  for  Arthrodesis  of  the  Astragalo-scaphoid  Joint,  for 
Valgus  Foot  Strain  and  Partial  Paralysis. — This  operation  is  done  for 
weakness  or  partial  paralysis  of  the  plantar  muscles.  Sometimes  when 
one  or  both  tibials  are  weak,  allowing  the  foot  to  sag  and  causing  a 
strain  at  this  joint,  there  is  often  an  intermittent  pain. 

The  patient  lies  on  his  back.  For  operation  on  the  right  foot,  a  pillow 
is  placed  under  the  right  knee,  flexing  it  to  about  thirty  degrees,  the 
operator  stands  on  the  same  side  as  the  foot  to  be  operated  on.  A  sand 
bag  is  placed  under  the  ankle  and  foot. 

An  incision  is  made  one-half  inch  forward  and  one-half  inch  below  the 
internal  malleolus,  two  inches  long,  extending  forward  almost  to  the 
head  of  the  first  metatarsal.  The  incision  is  carried  down  to  the  bone. 
The  anterior  tibial  and  posterior  tendons  are  avoided  and  retracted. 
A  small  osteotome  is  used  to  remove  the  cartilage  from  the  forward  end 
of  the  astragalus  and  from  the  adjoining  scaphoid.  The  denuded  bony 
surfaces  are  made  to  fit  smoothly  and  the  foot  is  adducted,  forcing  the 
bones  together.  The  position  of  the  foot  in  the  plaster  will  hold  the 
bones  together.  The  bones  may  be  drilled  and  a  kangaroo,  or  double 
chromic  catgut  suture,  used  to  fasten  the  bones  into  firm  apposition. 

The  deep  tissues  are  brought  together  with  interrupted  catgut  sutures 
number  00,  the  skin  with  continuous  chromic  catgut  sutures  number  00. 
The  foot  would  be  put  up  in  a  good  position  for  weight-bearing  plus  a 
slight  overcorrection  in  adduction  and  in  about  twenty-five  degrees  of 
dorsal  flexion.  The  position  should  be  one  useful  in  walking.  A  plaster 
of  Paris  bandage  is  applied  from  the  toes  to  the  middle  of  the  thigh  with 
the  knee  slightly  bent.  It  is  important  that  the  knee  should  be  bent  in 
order  that  the  plaster  will  not  rotate  on  the  leg. 

115.  Operation  for  Talipes  Calcaneous. — Where  the  tibialis  anticus 
is  very  strong  and  there  is  a  calcaneous  deformity,  due  to  complete  paral- 
ysis of  the  muscles  to  the  tendo  Achilles  one  of  the  peronei  muscles  or 
the  toe  flexors,  or  posterior  tibial,  may  be  transplanted  backward  to  the 
tendo  Achilles.  The  muscle  selected  will  depend  on  the  deformity. 
If  there  is  a  tendency  to  valgus  with  the  calcaneous  (see  figure  159), 
one  of  the  outer  muscles  should  be  used ;  if  there  is  a  tendency  to  varus 
one  of  the  inner  tendons  should  be  used.    In  some  cases  the  tibialis  an- 


OPERATION  FOR  DEFORMITIES  111 

ticus  or  the  long  toe  extensors  or  both  must  be  put  to  the  middle  or 
slightly  to  the  outer  side  of  the  middle  of  the  tarsus  in  order  to  make  up 
for  the  muscle  transplanted  backward.  Very  often  an  astragalectomy 
is  necessary  with  or  without  transplantation  of  muscles.  Tendon  fixa- 
tion of  the  tendo  Achilles  as  described  by  Dr.  Galli  may  be  used.  Short- 
ening of  the  tendo  Achilles  is  not  to  be  recommended.  Dr.  Galli's  tendon 
fixation  gives  added  life  to  the  paralyzed  tendon  from  the  cortex  of  the 
bone.  Shortening  a  paralyzed  tendo  Achilles  is  of  temporary  value  only, 
for  it  will  stretch  again. 

Operation  for  Astragalectomy  and  Displacement  of  the  Foot  Back- 
ward (see  under  Flail  Ankle)  section  168. 

Operation  for  Silk  Ligaments  at  the  Ankle  (see  under  Flail  Ankle) 
section  171. 

Operation  for  Tendon  Fixation  at  the  Ankle  (see  under  Flail  Ankle) 
section  174. 

Operation  for  Arthrodesis  at  the  Ankle  (see  under  Flail  Ankle) 
section  199. 

116.  Operation  for  Pes  Cavus. — The  pain  in  pes  cavus  is  most  fre- 
quently due  to  the  flexed  position  of  the  toes,  lack  of  upward  motion 
of  the  foot  and  lack  of  spring  due  to 
the  contracture.  The  toes  may  be 
corrected  by  an  operation  on  the  ten-  <C^ 
don,  and  sometimes  on  the  bone  of 
the  phalanges,  as  described  in  these 
pages  (see  Hammer  Toe).  Painful 
calluses  under  the  ball  of  the  foot 

are   due  to    the    position    of    the   toes        Fig.  177  —  Pes  cavus;  shaded  lines  indi- 
and  foot.      The  foot  deformity  cannot    fte  wedge  removed  from  the  astragalus, 
,  ^         .  .  to  allow  upward  motion  of  the  foot. 

always    be    relieved    by    wrenching 

and  tenotomy  of  the  tendo  Achilles  and  plantar  fascia.  In  extreme 
cases  there  is  little  or  no  upward  motion  of  the  foot.  It  is  necessary  to 
remove  a  small  wedge  from  the  astragalus  allowing  the  normal  upward 
motion  of  the  foot  (see  figure  177).  When  sufficient  overcorrection  is 
obtained  in  this  manner  a  tenotomy  of  the  plantar  fascia  should  be  done. 
When  the  pes  cavus  is  due  to  paralysis  and  the  other  leg  is  not  par- 
alyzed the  deformity  gives  length  to  the  leg  and  should  not  be  interfered 
with  when  there  is  no  pain. 

Pes  Cavus  Operation  on  the  Bone 
mr.  jones'  operation 

(A)  Calcaneo-cavus  where  the  calf  paralysis  is  complete. 

The  operation  is  to  be  done  in  two  stages,  four  weeks  intervening. 

Stage  I.  Divide  the  plantar  fascia  if  contracted,  and  wrench  with  hand 
or  instrument.  Make  an  incision  down  to  bone  about  three  inches  in 
length  on  the  inner  side  of  the  foot;  the  centre  of  the  incision  being 


112  TECHNIQUE  OF  OPERATIONS 

opposite  the  angle  of  convexity.  With  periosteum  elevator,  separate 
the  soft  structures  from  the  tarsus  above  and  below  from  the  inner  to 
the  outer  side.  Remove  a  transtarsal  V-shaped  section  of  bone  (see 
figure  178).  If  there  be  valgoid  deformity  let  the  section  be  wider  on 
the  inner  than  on  the  outer  side.  Suture,  and  obliterate  the  cavus  de- 
formity by  extending  the  foot  which  is  not  bandaged  to  the  tibia,  the 
calcaneous  deformity  being  apparently  much  increased  (see  figure  179). 
More  sheet  wadding  is  applied  to  the  leg  and  foot  and  a  plaster  of  Paris 
bandage  from  the  toes  to  the  knee  holds  the  foot  in  thirty  degrees  flexion. 
It  is  often  necessary  to  use  a  piece  of  saddle  felt  under  the  ball  of  the 
foot  in  addition  to  the  sheet  wadding  as  pressure  here  is  often  painful. 
The  hammer  toe  should  be  corrected  at  the  same  time  (see  Hammer  Toe 
Operation).  The  plaster  should  be  split  on  both  sides  so  that  the  front 
can  be  removed  and  the  incision  inspected.     This  plaster  is  worn  for 


B 

178. — Wedge  removed    (after  Fig.    179. — Closing    the    gap 

Mr.  Jones).  after  removing  the  wedge. 

four  weeks.  After  that  time  the  plaster  is  rapidly  removed  as  the  patient 
acquires  strength  in  walking. 

Four  weeks  after  the  wedge  of  bone  has  been  removed  from  the 
astragalus,  Mr.  Robert  Jones  has  suggested  removing  a  wedge  from 
the  os-calcis  to  completely  correct  the  cavus  (see  figures  178  to  181). 

Stage  II  (four  weeks  later). 

Make  a  longitudinal  incision  at  back  of  heel,  the  centre  being  opposite 
the  ankle-joint.  Open  the  joint  and  take  a  wedge  from  the  astragalus, 
sufficiently  large  to  be  accurately  obliterated  when  the  foot  is  brought 
to  right  angles.  Denude  tibia  and  fibula  of  cartilage  (see  figure  180). 
The  foot  should  be  brought  to  right  angles  and  fixed  immovably  until 
union  is  complete  (see  figure  181). 

(B)  Calcaneo-cavus  where  some  power  remains  in  the  calf  muscle. 

Stage  I  as  before. 

Stage  II.  Shorten  the  capsule.  Shorten  the  tendo  Achilles,  remove  a 
skin  flap  and  after  three  weeks,  massage  the  gastrocnemius.  In  this 
case  it  is  not  advisable  to  remove  bone.  In  older  subjects  it  may  be 
necessary  when  removing  a  wedge  to  incise  the  outside  as  well  as  the 
inside  of  the  foot.  For  some  weeks  after  walking  has  commenced  the 
foot  should  be  protected  against  strain. 


OPERATION  FOR  DEFORMITIES  113 

In  cases  where  the  leg  is  shorter  than  its  fellow,  it  is  often  undesirable 
to  do  the  operation  on  the  os-calcis,  if  the  tendo  Achilles  has  sufficient 
tension.  The  vertical  position  of  the  os-calcis  increases  the  length  of  the 
leg  and  no  pain  is  usually  experienced  after  the  correction  of  the  astrag- 
alus which  allows  normal  dorsal  motion  of  the  foot.  It  is  always  im- 
portant to  correct  the  flexion  of  the  toes  at  the  metatarso  phalangeal 
joints  so  that  these  bones  may  be  flexed  seventy-five  degrees  with  ease. 
The  hammer  toe  should  also  be  corrected  (see  Operation  for  Hammer 
Toe),  section  118.  Six  weeks  after  the  bone  operation  the  patient  is 
allowed  to  bear  weight  on  the  feet  with  the  plaster  twice  daily,  ten  to 
twenty  steps.  This  is  increased  as  the  case  allows,  every  two  or  three 
days.  After  two  weeks  most  patients  can  walk  short  distances  about 
the  house  with  the  plaster.     When  walking  is  sufficiently  good,  the 


^C3 


A      w  3 

Fig.  180. — Mr.  Jones'  opera-  Fig.  181. — Bone  brought  together  after  re- 

tion.    Stage  II  (after  Mr.  Jones).  moving  the  wedge. 

Wedge  removed. 

patient  is  allowed  to  walk  without  the  plaster  a  little  at  a  time.  Four 
months  after  the  operation  he  walks  without  supports. 

117.  Deformities  Limiting  the  Motion  of  the  Ankle  Joint  Following 
Potts  Fracture. — When  the  deformity  is  in  the  tibia  and  fibula  a  sub- 
cutaneous osteotomy  may  be  done  through  the  tibia  and  fibula  allowing 
correction  of  the  deformity.  A  small  incision  is  made  over  the  de- 
formity in  the  lower  third  of  the  fibula  and  the  lower  third  of  the 
tibia.  These  bones  are  cut  through  with  an  osteotome  and  the  de- 
formity corrected. 

The  foot  should  be  manipulated  with  or  without  a  wrench  as  the 
case  requires  so  that  complete  dorsal  motion,  adduction  and  abduc- 
tion of  the  foot  is  allowed.  The  foot  should  be  put  up  with  thirty 
degrees  dorsal  flexion,  the  plaster  extending  from  the  toes  to  the 
groin,  the  knee  slightly  flexed.  At  the  end  of  three  weeks,  the 
patient  is  allowed  to  walk  with  crutches  and  a  straight  plaster  is 
applied.  In  the  fifth  week  he  begins  to  bear  weight  on  the  leg  with 
the  plaster. 

When  the  alinement  of  the  tibia  and  fibula  is  good,  the  astragalus  will 
sometimes  infringe  on  the  tibia  limiting  the  motion  of  the  foot.  To 
correct  this,  a  wedge  of  bone  is  removed  from  the  astragulus  sufficiently 


114 


TECHNIQUE  OF  OPERATIONS 


large  to  allow  thirty  degrees  of  dorsal  motion  of  the  foot.  A  foot 
stretcher  will  be  found  of  service  in  relieving  the  contractures  of  the  soft 
tissues  that  contribute  to  the  defornuty. 

118.  Hammer  Toe  Operation.  Clawfoot  (see  figures  182  to  187). — 
Sometimes  this  condition  can  be  corrected  by  stretching  the  toes;  when 
this  is  sufficient  an  operation  is  unnecessary.  To  cor- 
rect a  more  extensive  deformity  it  is  usually  necessary 
to  tenotomize  or  lengthen  the  extensor  longus  digi- 
torum,  tenotomize  the  toe  flexors  and  sometimes  do  a 
tenotomy  of  the  metatarso  phalangeal  capsule  and 
relieve  the  capsular  shortening  of  the  joints  beyond 
the  metatarsal.  Besides  this  a  small  piece  of  bone 
must  often  be  removed  from  the  proximal  end  of  the 
phalanges. 

Sometimes  a  tenotomy  and  stretching  of  the  toe  is 
sufficient.  When  the  tenotomies .  have  been  done  if 
Fig.  182.  —  Hammer  the  toe  readily  adopts  its  deformed  position  the  cor- 
toe.  Claw  foot.  rection  will  not  be  satisfactory  without  operation  on 
the  bone.  It  is  of  course  possible  to  stretch  and  tear  the  joint  until  it 
straightens  out,  but  this  adds  injury,  with  resulting  swelling  and  pain, 
making  it  difficult  to  maintain  over- 
correction. It  is  simpler  to  incise, 
remove  a  small  piece  of  bone  with- 
out stretching  and  tearing,  without 
roughness,  and  obtain  complete 
overcorrection  with  almost  no  swell- 
ing if  the  operator  handles  the  toe 
gently.  The  result  is  more  satisfac- 
tory to  both  patient  and  operator.  When  the  case  is  of  long  standing, 
it  is  better  to  resort  to  the  bone  operation  from  the  first,  then  do  what 

tenotomies  are  necessary  without 
extensive  manipulation.  For  the 
different  methods  of  tenotomy  of 
the  tendons  involved,  the  reader 
is  referred  below.  The  removal  of 
bone  as  described  below  is  by  far 


Fig.  1S3. — Skeleton  of  claw  foot. 


Fig.  184.  —  Sub- 
luxated  phalanx.  A 
deformity  a  c  c  o  m- 
panying  claw  foot  or 
hammer  toe. 

the  simplest  way 
to  correct  an  ex- 
treme    hammer 


fb    ^> 


Fig.    1S5.  —  Incision      Fig.  186.— Shaded 


toe.    The  adjust-   f°r  reacmnS  the  phalan-   line    indicates    bone 
^        r    x  i_       geal  bones  or  joints.         removal. 

mentoithe 


Fig.  187.— Shaded 
line  indicates  joint 
removal. 


shortened  tissues  is  immediate  and  without  cutting  them.  The  opera- 
tor must  never  overlook  the  deformity  of  the  joint  above  and  below 
the  main  deformity. 


OPERATION  FOR  DEFORMITIES 


115 


119.  Hammer  Toe  and  Clawfoot.  Contracted  Extensor  Longus 
Digitorum  and  Hammer  Toe  Deformity  (sec  figures  182  to  187;. — 
When  a  hammer  toe  is  of  long  standing,  an  operation  is  usually  done  to 
relieve  the  contracted  tendon  which  extends  the  phalanx  on  the  meta- 
tarsal. When  the  cause  of  extension  of  the  phalanx  is  due  to  the  con- 
stant use  of  the  extensor  of  the  toe  to  raise  the  foot  in  walking,  it  is 
advisable  to  insert  these  tendons,  either  into  the  tarsus  higher  up  or 
into  the  head  of  the  metatarsal  bones  and  completely  separate  the 
tendons  below  from  the  toe. 

120.  Hammer  Toe  and  Clawfoot.  Subcutaneous  Tenotomy  of 
Extensor  Longus  Digitorum  near  the  Head  of  the  Metatarsal. — Where 
the  extensor  contraction  is  very  slight  but  needs  opera- 
tion, a  subcutaneous  tenotomy  of  the  extensors  of  the 
toes  may  be  done  as  shown  in  figure  188.  The  opera- 
tor feels  for  the  tendon  with  the  finger  of  the  right 
hand,  enters  the  skin  vertically,  to  one  side  of  the 
tendon,  lifts  the  skin  with  the  side  or  the  dull  edge  of 
the  tenotome,  and  slides  it  under  the  skin  over  the 
tendon.  The  blade  is  inserted  on  the  side  of  the 
tendon  beyond.  The  operator  puts  the  tendon  on  a 
stretch  by  flexing  the  toe  and  the  tendon  is  cut  across 
with  a  gentle  sawing  motion.  The  cutting  of  the 
tendon  gives  the  same  sensation  as  the  cutting  of 
celery.    When  the  tendon  is  completely  cut  across 

there  is   a   snap   and  the 
toe  will  be  relaxed. 

When     there     is     very      Fig.  188—  Subcu- 
siight  hammer  toe  and  no  taneous  tenotomy  of 

,  •      ,  i  i       ,  i        the  toe  extensor. 

change  in  the  capsule,  the 

operation  may  be  done  with  ethyl  chloride 

anaesthesia. 

121.  Hammer  Toe  and  Clawfoot.  Tenot- 
omy of  the  Extensor  Longus  Pollicis  near 
the  Head  of  the  Metatarsal.  Open  Tenot- 
omy.— Two  longitudinal  incisions  are  made 
(see  figures  189,  305),  one  over  and  parallel  to 
the  second  metatarsal,  and  the  other  over 
and  parallel  to  the  fourth  metatarsal; 
Fig.  189.— Open  operation  through  these  incisions  by  retracting  to 
for  tenotomy  of  the  contracted  one    s[^e   and   then   to   the   other   all   the 

long  toe  extensors.  ■,  -i  ■,      1  ■,    ,  ■       ■, 

tendons  are  easily  reached  and  tenotomized 
without  injuring  other  tissues.  Tenotomies  of  the  capsules  are  usu- 
ally necessary  and  manipulation  and  stretching  of  the  toe  at  each 
joint. 


116  TECHNIQUE  OF  OPERATIONS 

122.  Hammer  Toe  and  Clawfoot.  Operation  for  Tenotomy  or  Ten- 
don Lengthening  the  Extensor  Longus  Digitorum  Tendons  in  the 
Leg. — The  patient  lies  on  his  back,  the  operator  stands  on  the  side  of 
the  leg  to  be  operated  on 

An  incision  is  made  two  inches  long  over  the  front  and  lower  third  of 
the  leg  through  the  skin  and  fat.  The  skin  and  subcutaneous  fat  are 
retracted  and  the  anterior  tendons  are  exposed.  Lifting  each  tendon 
on  a  blunt  instrument  will  give  sufficient  pull  to  show  to  which  toe  it 
extends.  Each  extensor  tendon  may  be  cut  with  a  tenotome  halfway 
through  on  one  side  and  halfway  through  on  the  other  at  a  different 
level,  pulled  down  and  sutured  as  described  elsewhere  for  tenotomy 
of  the  tendo  Achilles  (see  figures  216  to  217),  or  one  of  the  other  methods 
of  tendon  lengthening  should  be  used,  described  elsewhere  in  these  pages 
under  tendon  lengthening  (section  127) 

After  a  simple  tenotomy,  the  foot  is  put  up  in  a  plaster  of  Paris  band- 
age in  an  equinus  position  for  about  a  week,  then  brought  up  to  right 
angles.  The  patient  is  then  allowed  to  walk  with  the  plaster  after  the 
third  week.  After  that  the  plaster  may  be  removed  part  of  each  day 
and  rapidly  discarded. 

After  a  tendon  lengthening  the  patient  should  not  walk  on  the  foot 
for  seven  or  eight  weeks.  At  first  he  walks  a  little  with  the  plaster  on. 
The  length  of  time  is  gradually  increased  and  the  plaster  omitted  a  little 
each  day  until  walking  has  become  easy.  This  operation  will  rarely 
be  needed,  for  where  the  extensor  tendons  have  become  excessively 
strong  and  consequently  short,  it  is  better  to  put  them  into  the  tarsus 
and  use  them  to  raise  the  foot  rather  than  to  lengthen  them. 

123.  Hammer  Toe  and  Clawfoot.  Operation  on  the  Bone  (see  figures 
185,  187). — An  incision  three-fourths  of  an  inch  long  is  made  to  the 

inner  or  outer  side  of  the  dorsal  tendon  down 
to  the  bone.  The  incision  through  the  skin  and 
fat  should  be  made  in  one  layer  in  order  to  keep 
the  flaps  as  thick  as  possible.  If  the  toe  shows 
pressure  from  the  shoe  more  on  one  side  than 
FlG  190  Hpi^ster  digit  ^Ge  other,  the  side  showing  the  least  pressure 
for  maintaining  correction  should  be  chosen  for  the  incision.  The  incision 
a^°eprerationsontnetoes  is  made  as  snown  in  figure  185.  It  is  carried 
down  to  the  bone,  the  periosteum  of  the  proxi- 
mal end  of  the  phalanx  cut  through  and  then  lifted  by  means  of  a 
small  sharp  osteotome.  The  tissues  must  be  freed  subperiosteally  before 
the  bone  can  be  removed.  This  subperiosteal  dissection  is  made  with 
a  small  sharp  osteotome  which  minimizes  the  injury  to  all  the  soft  parts. 
A  small  portion  of  this  bone  is  removed  enough  to  allow  the  joint  to  be 
overcorrected  without  force  (see  shaded  portion  of  figure  186).  The 
joint  should  be  perfectly  loose  and  able  to  flex  or  extend  after  removing 
the  bone.  At  the  time  of  the  operation,  it  is  almost  always  necessary 
to  relieve  the  extended  position  of  the  joint  above  the  one  flexed  and 


OPERATION  FOR  DEFORMITIES 


117 


often  a  tenotomy  of  the  extensor  tendons,  or  capsule  of  the  joint  above, 

is  necessary.     When  the  tenotomies  are  necessary  besides  the  bone 

operation  the  reader  is  referred  to  the  descrip-    .  t 

tion    of    tenotomy    of 

these  tendons.     If  the 

operator     chooses     to 

excise  the  joint  instead 

of   removing  the  bone 

from  the  proximal  end 

of  the  second  phalanx 

alone,    he    operates   as 

follows. 

124  Hammer  Toe 
Operation  and  Claw- 
foot.  Joint  Excision. — 
An  incision  is  made  as 


Fig.  192.  —  Splints  for 
holding  the  toes.  Multiple 
bent  copper  wire  rectangles 
applied  to  ankle  cuff  and 
foot  cuff  and  held  by  ad- 
hesive bands. 


Fig  191.— Splints  for 
in  the  previous  opera-  holding  the  toes,  sheet 
tion  (see  figure  187),  wadding  cuff  and  bandage 
,  v         ,       ,  /,i        over  ankle  and  foot. 

down  to  the  bone  (the 
incision  need  not  be  more  than  three-fourths  of  an  inch  long).  The 
periosteum  is  incised  by  means  of  a  small  sharp  osteotome;  it  is 
raised  and  an  excision  of  the  joint  performed  by  subperiosteal^ 
cutting  the  distal  end  of  the  proximal  phalanx  and  the  proximal  end  of 
the  second  phalanx.  Enough  bone  is  removed  to  allow  very  free  exten- 
sion and  flexion  of  the  joint.  It  is  usually  necessary,  in  a  hammer  toe 
operation,  to  do  a  tenotomy  of  the  extensor  of  the  joint  just  above,  and 
sometimes  of  the  capsule  of  that  joint  to  allow  easy  flexion  at  that 
point  (see  Operation  on  Extensor  Tendons  of  the  Toes,  section  154). 
The  subcutaneous  tissues  may  be  brought  together  with  interrupted 
chromic  catgut  sutures  number  00  and  the  skin  with  continuous  chro- 
mic catgut  sutures  number  00.  A  wire  splint  (see  figures  191  to  194) 
with  adhesive  or  a  wooden  plantar  splint,  well  padded,  is  applied  to  the 
whole  foot  and  toes  operated  on  and  a  plaster  of  Paris 
bandage  over  this,  a  special  plaster  rope  or  finger  is 
applied  beyond  each  toe  (see  figure  190).  When 
;  • ,  j  —Post  i-  *ne  °Perator  has  handled  the  toe  gently  there  is  practi- 
erative  hammer  toe  cally  no  swelling  after  five  days.  The  patient  should 
splint.  A,  Represents  ^g  taught  to  passively  hyperextend  and  stretch 
bentetoWhyperextend  the  toes  where  they  were  flexed  and  to  flex  the 
the  toe.    b,  Felt  pad  metacarpo  phalangeal  joints  which  were  extended. 

STdthe  toePereXtend"    This   is  d°ne   five    t0    ten   tlmeS'   f0Ur   tlmeS   a  day* 
The  patient  walks  with  the  plaster  in  two  weeks. 

The  toe  should  be  given  freedom  in  a  moccasin  after  that  for  two  or  three 

weeks,  then  a  very  broad  shoe  used.    The  stretching  exercises  are  kept  up 

by  the  patient  twice  daily  for  eight  weeks.    The  treatment  must  vary 

for  the  individual  case. 


118 


TECHNIQUE  OF  OPERATIONS 


Callouses  under  the  ball  of  the  foot  are  usually  due  to  a  contracted 
condition  of  the  overlying  joint  which  nature  protects  by  callouses. 
To  overcome  a  callous  which  is  often  painful  it  is  necessary  to  overcome 
the  extension  of  the  toe  and  flexion  of  the  phalanx  or  both  as  the  case 
may  be.  When  the  deformities  are  overcome,  the  callous  may  be  treated 
and  will  gradually  disappear. 

125.  Operation  for  Hallux  Valgus. — Hallux  Valgus  often  accom- 
panies other  deformities.  Where  the  hallux  valgus  deformity  is  not 
extreme,  a  tenotomy,  preferably  a  zigzag,  of  the  extensor  of  the  great 
toe  may  be  done  and  an  osteotomy  performed  through  the  base  of  the 
head  of  the  metatarsal  (see  figures  195,  196). 

A  longitudinal  incision  is  made  one  inch  long  to  the  inner  side  of  the 
tendon  of  the  great  toe  over  the  head  of  the  metatarsal  (figure  197). 
The  incision  is  carried  down  to  the  bone,  an  osteotomy  is  performed 
through  the  head  of  the  bone  (figure  195),  and  the  deformity  over- 
corrected  at  the  point  of  osteotomy. 

An  osteotomy  requires  a  very  small  incision. 


Fig.  194. — A  d  h  e  s  i  v  e 
bands  holding  wire  and 
foot  and  ankle  cuffs. 
Splints  for  holding  the 
toes. 


Fig.    195. — Osteotomy   for 
hallux  valgus. 


Fig.   196. — Wedge  of  bone 
removed  for  hallux  valgus. 


No  dissection  of  the  tissues  from  the  bone  is  necessary,  excepting  im- 
mediately at  the  point  of  incision.  This  will  give  little  swelling  and  good 
correction.  It  should  be  done  close  to  the  joint.  The  subcutaneous  tis- 
sues are  brought  together  with  interrupted  chromic  catgut  sutures  num- 
ber 00,  the  skin  with  continuous  chromic  catgut  sutures  number  00.  A 
wooden  plantar  splint  is  applied  (figure  198)  to  hold  the  toe  in  overcorrec- 
tion. This  splint  should  be  made  before  the  operation  from  a  tracing  of 
the  foot  (see  figure  200) .  It  is  applied  as  shown  in  figure  199.  A  plaster  is 
applied  from  the  middle  of  the  calf  to  the  toe  holding  the  foot  at  right 
angles  over  the  splint.  The  plaster  is  split  on  either  side  so  that  the 
top  may  be  removed  and  the  dressing  inspected  without  disturbing 
the  position  of  the  foot  and  toe.  If  one  foot  alone  has  been  operated 
upon  the  patient  may  walk  freely  on  the  other  foot  as  soon  as  the 
swelling  has  disappeared  and  the  wound  has  entirely  healed  but  not 
sooner  than  ten  days.    A  child  is  kept  in  bed  two  weeks  but  he  may 


OPERATION  FOR  DEFORMITIES 


119 


be  allowed  to  sit  up  in  bed.  No  walking  on  the  foot  should  be  allowed 
until  the  fifth  week.  The  metatarsal  head  may  be  cut  by  a  chain  saw, 
applied  around  the  head  of  the  metatarsal  by  means  of  a  special  in- 
strument devised  by  Dr.  Osgood. 

Sometimes  a  wedge  of  bone  is  removed  to  allow  correction  of  the  toe. 
For  removing  a  wedge  of  bone  the  same  incisions  are  used,  a  small  wedge 


Fig.  197.— Shaded 
portion  of  bone  re- 
moved from  the  dor- 
sal but  not  the  plan- 
tar surface  of  the 
metatarsal  for  hallux 
valgus. 


Fig.  198. —Post 
operative  plantar 
wooden  splint  for 
hallux  valgus,  show- 
ing correction  (see 
figure  200). 


Fig.  199.  — Plas- 
ter applied  over 
plantar  splint  fol- 
lowing hallux  valgus 
operation. 


of  bone  is  cut  with  an  osteotome  from  the  base  of  the  head  of  the  meta- 
tarsal (see  figure  196) ,  or  the  bone  may  be  removed  from  the  upper  and 
outer  side  of  the  head  of  the  metatarsal  (see  figure  197),  leaving  the 
weight-bearing  portion  of  the  metatarsal  on  the  plantar  surface.  This 
should  never  be  removed.  Most  cases  do 
well  with  almost  any  operation  carefully 
done.  The  cases  that  do  badly  and  are  crip- 
pled afterward  are  those  where  the  head  of 
the  bone  has  been  removed  or  else  the 
weight-bearing  portion  of  the  bone  interfered      FlG-  200.— The  striped  fines 

.,,  outline  the   application  of  the 

Wltn.  adhesive  to  the  splint  to  hold 

Any  small  exostoses  on  the  tip  of  the  meta-  the  toe  adducted.   Padding  is 
tarsal  may  be  removed  with  an  osteotome.  put  over  the  toe  first' 
Patients  with  osteo-arthritis  and  those  with  infectious  arthritis  may 
get  a  stiff  joint  following  this  operation.    It  is  to  be  avoided  there- 
fore in  these  cases. 


CHAPTER  II 

MUSCLE    AND    TENDON    OPERATIONS — MUSCLE    AND    TENDON 
TRANSPLANTATION 


126.  General  Principles  in  Simple  Tenotomies,  Tendon  Lengthening 
and  Tendon  Shortening. — A  tenotomy  is  a  simple  way  of  relieving  the 
tension  due  to  a  short  tendon.  Regeneration  of  a  tendon  is  extremely 
good,  especially  the  regeneration  of  certain  tendons  like  that  of  the 
tendo  Achilles.  Subcutaneous  tenotomy  should  not 
be  performed  where  there  are  important  blood  vessels, 
or  nerves,  which  might  be  accidentally  cut  during  the 
operation.  In  tenotomizing  a  tendon  it  is  important 
not  to  cut  the  whole  of  the  sheath  at  the  point  of 
tenotomy.  Experimentally  it  has  been  shown  by 
Dr.  Sever  and  others  that  regeneration  of  a  tendon  is 
favored  by  the  presence  of  part  of 
the  tendon  sheath.  Where  the 
sheath  is  entirely  cut  across,  regener- 
ation between  the  ends  of  the  tendon 
is  apt  to  be  wholly  by  scar  tissue. 
When  some  of  the  sheath  remains, 
the  tendon  itself  regenerates.  A 
tenotomy  is  such  a  simple  opera- 
tion that  when  tenotomy  of  the 
tendo  Achilles  has  been  described 
there  will  be  no  need  of  describing 
the  operation  for  other  tendons. 
127.  Open  Operation  for  Tendon 
Fig.  201.— Zig-zag  Lengthening. — The  skin  and  fat  are 
tenotomy  of  the  incised  and  retracted  exposing  the 
tendon.  A  slit  one-half  inch  long 
is  made  parallel  to  the  tendon  fibers 
vertically  through  its  middle,  and  the  slit  connected 
with  one  at  right  angles  at  each  end,  one  on  the  out- 
side of  the  tendon  at  one  end,  the  other  on  the  inside  of 
the  tendon  at  the  other  end  (see  figures  201,  202). 
The  ends  are  sutured  or  left  free.  The  tendon  may 
be  slit  diagonally  from  front  to  back,  or  diagonally  from  side  to  side 
with  or  without  suture  of  its  ends.  The  tendon  sheath  is  closed  loosely 
over  the  tendon.  The  subcutaneous  fat  and  skin  are  brought  together 
with  interrupted  chromic  catgut  sutures  number  00. 

For  conditions  other  than  poliomyelitis  and  sometimes  in  poliomy- 

120 


tendo    Achilles 
good  method. 


Fig.  202.    The  ten- 
don drawn  out. 


MUSCLE  AND  TENDON  OPERATIONS 


121 


elitis,  if  the  deformity  has  been  of  long  standing,  or  due  to  a  fracture  or 
dislocation,  it  must  be  remembered  that  there  are  probably  other  tissues 
maintaining  the  deformity 
beside  the  tendons.  If 
these  are  bone,  more  ex- 
tensive operations  will  be 
necessary.  If  the  deform- 
ity is  due  to  fibrinous 
adhesions  or  due  to  con- 
tractures of  the  soft  tis- 
sues only,  manipulation 
and  stretching  should  ac-  FlG-  203-X  marks  point  for  inserting  tenotome- 
company  the  tenotomy.  The  operator  should  have  some  form  of  foot 
stretcher  on  hand,  such  as  the  Thomas  wrench  or  one  of  Dr.  Bradford's 
club  foot  wrenches  or  Dr.  Davis'  foot  stretcher. 

In  the  case  of  spastic  condition  of  the  muscle,  a  tenotomy  is  often 
unnecessary  to  correct  any  equinus  that  is  present.  Should  tenotomy 
of  the  tendo  Achilles  be  done  in  spastic  paralysis, 
the  foot  must  be  brought  to  a  right  angle  position  in 
from  three  to  five  days  after  operation.  In  cases  of 
spastic  paralysis  in  which  a  tenotomy  has  been  per- 
formed, the  foot  is  put  up  at  first  in  five  degrees  or 
ten  degrees  of  dorsal  flexion  rather  than  more.  Spastic 
muscles  at  the  ankle  do  not  accommodate  themselves 
readily   to    an   over-stretched   position.     When   the 


Fig.  204.  —  Inser- 
tion of  tenotome  un- 
der the  skin  across 
the  tendon. 


Fig.  205.- 


-Cutting  the  inner  half  of  the  tendo  Achilles 
at  a  higher  level. 


tendon  to  be  lengthened  overlies  the  belly  of  the  muscle  in  part  of  its 
course,  the  tendon  may  be  lengthened  here. 

The  skin  incision  should  be  to  one  side  of  the  line  of  the  tendon  and 
when  closed  the  fat  brought  over  the  tendons  and  carefully  sutured. 
The  tendons  should  be  handled  as  little  as  possible  and  not  injured  by 
hard  forceps  or  by  clamping.  Any  ends  of  tendons  that  are  to  be  cut 
away  may  be  clamped. 


122 


TECHNIQUE  OF  OPERATIONS 


In  subcutaneous  tenotomy  of  the  tendo  Achilles  (figures  203  to 
206)  it  may  be  incised  posteriorly  or  laterally,  cutting  away  from 
the  skin.  Cutting  the  skin  is  apt  to  cause  small  adhesions  which  may 
be  avoided  by  cutting  away  from  it. 

An  open  incision  and  lengthening  of  the  tendo  Achilles  is  here  de- 
scribed, as  it  is  sometimes  necessary.  It  is  an  unnecessary  operation  in 
the  majority  of  cases,  especially  when  it  is  done  in  connection  with  other 
operations  which  is  ver}'  often  the  case.  A  subcutaneous  tenotomy 
of  the  tendo  Achilles  may  be  done  in  a  minute  which  does  not  prolong 
the  operation  to  any  degree.     In  the  case  of  other  tendons,  open  length- 


Fig.  206. — Cutting  the  outer  half  of  the  tendo  Achilles 
at  a  lower  level.  When  the  tendon  is  stretched  a  zig- 
zag subcutaneous  tenotomy  results.    (See  figure  201.) 

ening  may  be  advisable  and  is  often  the  operation  of 
choice.  A  subcutaneous  tenotomy  is  preferable  for  the 
Achilles  tendon  even  when  there  are  scars  of  previous 
tenotomies.  No  danger  of  non-union  need  be  feared. 
In  a  large  clinic  where  thousands  of  tenotomies  have 
been  done,  lack  of  union  following  tenotomy  has  almost 
never  been  seen.  Occasionally  a  writer  reports  a  non- 
union of  the  tendo  Achilles.  In  hospitals  this  opera-  "  FlG.  207.— Teno- 
tion  is  apt  to  be  delegated  to  those  less  skilled  in  tomy  across  the 
operating.  In  spite  of  this  the  cases  of  non-union  are  £gst  method*  the 
few.  A  non-union,  we  are  led  to  believe,  is  due  to  the 
complete  cutting  of  the  sheath  combined  with  careless  after  treatment. 
Tenotomy  of  the  tendo  Achilles  is  usually  performed  to  relieve  equinus, 
or  to  allow  more  upward  motion  of  the  foot.  More  detail  in  the  tech- 
nique of  tenotomy  is  given  below. 

128.  Operation  for  Subcutaneous  Tenotomy  of  the  Left  Tendo 
Achilles  (figure  207). — The  surgeon  holds  the  ball  of  the  foot  in 
the  left  hand.  By  pressure  he  is  able  to  tighten  or  loosen  the  tendo 
Achilles.  The  tenotome  is  passed  vertically  through  the  skin.  The 
tenotome  should  enter  the  skin  some  distance  from  the  tendon  (see 
figure  203),  point  X.  The  tendon  having  pierced  the  skin,  the  tendo 
Achilles  is  relaxed.  The  blade  of  the  knife  is  passed  under  the 
skin  and  over  the  tendon  until  it  has  crossed  to  the  other  side.     The 


MUSCLE  AND  TENDON  OPERATIONS  123 

blade  is  then  turned  down  on  the  tendon  (see  figures  204  to  206).  The 
surgeon  tightens  the  tendon  with  the  left  hand  by  pressure  on  the  ball 
of  the  foot  during  the  cutting.  The  last  part  of  the  tendon  is  torn  by 
the  tension.  This  saves  part  of  the  tendon  sheath.  The  tenotome  by 
a  gentle  sawing  motion  gradually  cuts  through  the  tendon.  The  cutting 
gives  the  same  sensation  as  when  celery  is  cut  through.  The  tendon  is 
stretched  and  the  foot  brought  up,  over-correcting  the  equinus.  In  all 
cases  where  the  tendo  Achilles  is  tenotomized  the  foot  should  be  held 
afterward  in  a  firm  plaster  of  Paris  bandage  extending  from  the  toes 
to  the  knee  for  from  five  to  six  weeks.  The  foot  should  be  dorsally 
flexed  at  least  twenty  degrees  from  the  right  angle.  Walking  on  the  foot 
is  allowed  with  the  plaster  in  four  weeks  from  the  time  of  operation. 

129.  Operation  for  Talipes  Equinus  (see  figure  159). — The  position 
of  equinus  is  often  due  to  a  simple  contracture  of  the  tendo  Achilles 
readily  relieved  by  a  tenotomy.  When  complicated  by  a  contracture 
of  the  other  posterior  tendons  on  both  sides  and  the  capsule  and  joint 
ligaments,  stretching  by  means  of  one  of  the  wrenches  described  in 
another  chapter  may  be  used.  A  tenotomy  of  the  tendo  Achilles  is 
usually  sufficient  to  correct  the  deformity  when  it  is  simple. 

AFTER  TREATMENT 

130.  Following  the  tenotomy,  a  plaster  of  Paris  bandage  is  applied 
from  the  toes  to  below  the  knee;  the  patient  may  walk  on  the  unaffected 
leg  using  crutches.  It  is  better  to  remain  quiet  for  the  first  five  days.  In 
the  case  of  children,  they  should  remain  in  bed  for  one  week.  It  is  not 
necessary  after  the  first  twenty-four  hours  that  they  should  remain  at  a 
hospital.  Where  much  force  has  been  used  or  where  it  has  been  neces- 
sary to  use  wrenches,  the  patient  had  better  be  in  a  hospital  until  all 
swelling  has  subsided.  Walking  on  the  foot  with  the  plaster  is  allowed 
after  the  fifth  week  a  little  at  first.  A  wooden  plaster,  or  felt  wedge  is 
put  under  the  ball  of  the  foot  until  the  foot  is  brought  down  to  right 
angles.     The  plaster  is  gradually  omitted  as  walking  improves. 

In  most  instances  the  equinus  is  only  part  of  one  of  the  many  de- 
formities of  the  foot  described  below. 

131.  The  Plaster  of  Paris  Bandage  for  the  Foot  After  Operation  for 
Talipes  Equinus. — Following  a  tenotomy  of  the  tendo  Achilles,  the 
foot  should  be  put  up  in  a  plaster  of  Paris  dressing  with  plenty  of  well 
fitting  padding.  There  should  be  a  great  deal  of  sheet  wadding  or  other 
padding  about  the  heel  to  prevent  pressure  here.  When  the  surgeon 
has  applied  as  much  sheet  wadding  as  he  thinks  necessary  he  should 
apply  as  much  again  on  the  heel  to  be  sure  to  protect  it.  While  the 
plaster  is  drying,  no  pressure  should  be  allowed  to  dent  the  plaster, 
particularly  at  the  heel.  A  pillow  is  placed  under  the  calf  of  the  leg 
reaching  almost  to  the  heel,  keeping  it  off  of  the  table  or  bed.  The 
plaster  should  not  bend  the  toes  over  the  dorsum  of  the  foot,  but  hold 
the  whole  foot  evenly  raised,  the  toes  flat  in  line  with  the  ball  of  the  foot. 


124 


TECHNIQUE  OF  OPERATIONS 


A 


- 


/ 


\ 


As  soon  as  the  plaster  is  dry  it  should  be  split  on  both  sides.  It  may  be 
strapped  on  (see  figure  156)  or  held  by  means  of  a  wet  gauze  bandage  (see 
figure  158),  which  should  be  kept  broad  and  from  curling  at  its  edges  on 
the  back  of  the  plaster  and  at  the  side,  and  come  together  only  where 
it  is  tied.  Such  a  bandage  will  not  slip  or  curl;  the  top  of  the  plaster 
will  be  held  securely. 

Should  an  open  operation  be  necessary,  a  careful  dissection  is  made 
down  to  the  tendon,  the  skin  and  subcutaneous  incision  should  be  to 
one  side  of  the  tendon  and  not  overlying  it.  When 
the  tissues  have  been  retracted  exposing  the  tendon, 
it  is  tenotomized  either  directly  across  (figure  207), 
or  it  is  tenotomized  diagonally,  or  it  may  be  tenot- 
omized above  on  one  side,  and  below  on  the  other 
side  (see  figure  202),  and  the  tendon  drawn  out. 
Elaborate  methods  of  tenotomy  are  unnecessary  as 
they  simply  increase  the  chances  of  adhesions  with- 
out increasing  the  efficiency  of  the  tendon. 

132.  Subcutaneous  Zigzag  Tenotomy  of  the  Tendo 
Achilles. — A  tenotome  is  entered  through  the  skin  as 
described  above  (point  X,  figures  203  to  207).  The 
operator  holds  the  foot  as  in  the  case  of  the  straight 
tenotomy.  The  preparation  is  the  same.  The  ob- 
ject of  the  tenotomy  is  to  cut  the  tendon  at  the 
points  seen  in  figure  201  and  then  to  tear  the  tendon. 
The  tendon  sheath  is  not  cut  on  both  sides  at  the 
same  level  (see  figure  202).  The  surgeon  holds  the 
ball  of  the  foot  in  the  left  hand,  the  tenotome  is  en- 
tered vertically  through  the  skin  at  a  point  a  short 
distance  from  the  tendon  (see  figure  203)  point  X. 
The  surgeon  relaxes  the  tendon,  the  tenotome  passes 
under  the  skin  to  the  opposite  side  of  the  tendon, 
making  the  cut  at  figure  205;  it  is  next  drawn  a  lit- 
tle one  side  and  lowered  and  the  cut  (figure  206)  is 
made. 

The  operator  may  prefer  to  cut  the  tendon  diago- 
nally from  front  to  back  or  diagonally  from  side  to 
side,  subcutaneously. 
tome. '  Narrow  blade  Figure  206  represents  the  position  of  the  tenotome 
and  long  narrow  in  making  the  incision  on  the  outer  side  of  the  tendo 
blunt  collar.  Achilles.     After  the  tendon  is  cut  halfway  through 

on  the  outer  side,  it  should  be  cut  halfway  through  on  the  inner 
side,  at  a  level  one-half  an  inch  lower.  In  changing  the  position 
of  the  tenotome  the  surgeon  relaxes  the  pressure  on  the  ball  of  the 
foot  so  that  the  tendo  Achilles  is  relaxed,  allowing  the  tenotome  to 
be  brought  easily  into  position.  A  tenotomy  may  be  performed 
at    almost    any   level.      It    is   better,    however,    to    operate    on    or 


MUSCLE  AND  TENDON  OPERATIONS 


125 


near  the   round   portion   rather   than   the   flat    portion   of   the  ten- 
don. 

133.  The  Tenotome.— Figure  208  will  show  the  proper  shape  of 
the  tenotome  and  figure  209,  the  kind  of  tenotome  usually  found  at 
instrument  stores.  The  blade  of  a  good  tenotome  is 
very  small,  one-quarter  or  three-eighths  of  an  inch 
long  and  one-eighth  to  one-sixteenth  of  an  inch  in 
diameter.  The  neck  should  be  strong  and  not  sharp, 
and  long  enough  to  allow  the  blade  to  extend  some 
distance  inward  but  not  so  weak  in  the  neck  that  it 
will  break  or  bend. 

134.  Operation  for  Open  Tenotomy  to  Relieve 
Contracture  of  Flexor  Longus  Digitorum  in  the 
Lower  Leg. — When  this  deformity  accompanies  ex- 
tension of  the  metatarso  phalangeal  joint,  the  reader 
is  referred  to  a  fuller  description  under  Hammer 
Toe. 

As  the  patient  lies  on  his  back,  the  operator 
stands  on  the  same  side  as  the  leg  to  be  oper- 
ated on. 

An  incision  is  made  one-half  inch  directly  pos- 
terior to  the  internal  malleolus  and  two  inches  long, 
through   the   skin    and    subcutaneous   fat.     This  is 

dissected  up 
and  retracted 
exposing  the 
tendons,  a 
blunt  dissec- 
tor raises  the 
flexed  tendon 
of  the  toes 
which  the  sur- 
geon assures 
himself  he  has 
by  pulling  on 
the  blunt  dis- 
sector thereby  to°  large- 
contracting  the  toes.  A  zigzag 
3  q        tenotomy  or  a  tendon  lengthening 

Fig.  210.— Tendon  lengthening  in  the  belly    may    be    done    according    to    any 

of  the  muscle,  a  zigzag  tenotomy  may  be  0f  the  methods  described  under 

done  here.    (See  figure  201.)  ,  ,  ,  rT^1 

tendon  lengthening.  The  sub- 
cutaneous tissues  are  brought  together  with  interrupted  chromic  catgut 
sutures  number  00,  the  skin  with  continuous  chromic  catgut  sutures 
number  00.  A  well  padded  plaster  of  Paris  bandage  is  applied  holding 
the  feet  dorsally  flexed  and  the  toes  extended  by  "digit  ropes"  in  the 


Fig.  209.  —  Teno- 
tome usually  to  be 
found  for  sale.  The 
blade  is  too  long  and 


126 


TECHNIQUE  OF  OPERATIONS 


plaster  (see  figure  190).  The  case  is  allowed  to  walk  after  the  fifth  week 
with  plaster.  At  the  end  of  eight  weeks  if  the  patient  can  walk  well  the 
cast  is  gradually  omitted. 

135.  Subcutaneous  Tenotomy  of  the  Flexor  Longus  Digitorum  at 
the  Base  of  the  Toe. — A  subcutaneous  tenotomy  of  the  tendons  of  the 

toes  may  be  made  at  the  base  of  each  toe  or  at  the  toe 
under  the  second  phalanx.  The  tenotome  is  inserted 
in  each  case  to  the  side  of  the  tightened  tendon  which 
may  be  felt  as  the  toe  is  held  extended.  As  the  teno- 
tome is  slid  over  the  tendon  the  toe  should  be  relaxed. 
When  the  blade  reaches  the  farther  end  of  the  tendon 
the  toe  is  extended  allowing  the  rigid  tendon  to  come 
in  contact  with  the  blade.  The  tendon  is  then  cut 
across  by  a  gentle  sawing  motion.  As  the  fibers  are 
cut  they  give  the  sensation  of  cutting  celery.  The 
foot  is  put  up  in  plaster  with  toe  portion  hyperex- 
tending  the  toes.  This  remains  on  three  or  four 
weeks.  The  after  treatment  will  consist  of  extending 
the  toes  daily.  When  the  operation  of  extending  the 
flexed  tendons  of  the  toes  is  done  for  hammer  toe, 
the  extended  metacarpal  phalanx  joint  must  be  cor- 
rected as  well  as  the  flexed  phalangeal  joint  beyond, 
otherwise  the  operation  is  but  half  done.  A  toe 
splint  (see  figures  190  to  194),  the  toe  wire  bent 
to  correct  the  deformity  or  foot  plaster  should  flex 

the  metacarpo  phalangeal  joint  and  extend  the 

phalanges.     In  severe  cases,  apparatus  should 

be  worn  constantly  for  six  or  eight  weeks  and 

gradually  omitted    after    that.     Exercises  and 

stretching  of  the  toes  should  be  done  daily  for 

about  a  year;  otherwise  the  tendons  may  con- 
tract.   Apparatus  in  severe  cases  should  be  used 

an  hour  daily  for  a  year. 

136.  Subcutaneous  Tenotomy  of  the  Plantar 
Fascia.  (Subcutaneous  Tenotomy  of  the  Left 
Plantar  Fascia)  (figures  211  and  212). — In  doing 
a  tenotomy  the  shape  of  the  tenotome  is  impor- 
tant. It  should  have  a  narrow  blade  about  three- 
eighths  of  an  inch  long,  such  as  is  shown  in  fig- 
ure 208.  The  operator  holds  the  ball  of  the 
foot  in  the  left  hand  and  enters  the  tenotome  12.— Pass 
perpendicularly  through  the  skin  at  a  point  X  tenotome  between  the  skin 
in  figure  211.    The  skin  is  lifted  by  the  blunt  part  and  the  plantar  fascia- 

of  the  tenotome  while  the  tenotome  passes  between  the  skin  and  the  plan- 
tar fascia  (figure  212),  the  operator  being  careful  not  to  cut  the  under  sur- 
face of  the  skin  across  the  foot.     The  surgeon  should  feel  carefully  with 


Fig.  211.— Tenot- 
omy of  the  plantar 
fascia.  X;  points  of 
entrance  for  the  ten- 
otome. 


MUSCLE  AND  TENDON  OPERATIONS  127 

the  fingers  of  the  right  hand  for  the  fibers  which  he  wishes  to  relieve. 
By  a  gentle  sawing  motion'  of  the  blade  of  the  knife,  the  plantar  fascia 
is  cut  across;  the  cutting  of  its  fibers  gives  very  much  the  same  sensation 
as  that  of  cutting  celery.  The  fibers  are  all  cut  across  one  after  another 
without  penetrating  deeply  into  the  tissues.  If  the  surgeon  feels  with 
his  knife  while  he  is  cutting,  there  is  no  danger  of  extending  deeply 
beyond  the  fibers  of  the  fascia.  Before  withdrawing  the  knife  the 
surgeon  should  feel  for  any  fibers  that  remain  uncut.  It  is  distinctly 
advisable  not  to  cut  the  skin,  for  in  subsequent  stretching  of  the  foot 
later  it  is  apt  to  be  torn.  The  deep  tendons  should  also  be  avoided. 
Occasionally  there  is  some  bleeding  due  to  the  cutting  of  small  vessels. 
This  usually  does  not  amount  to  anything  and  requires  no  special 
treatment.  Gentle  pressure  with  the  fingers  is  sometimes  necessary 
when  the  bleeding  is  excessive.  'This  condition  is  rare.  Tenotomy  of 
the  plantar  fascia  is  usually  done  in  connection  with  other  operations 
to  correct  deformity.  It  is  often  necessary  in  operations  for  the  cor- 
rection of  equino  varus,  varus,  equinus  and  cavus. 

137.  Operation  for  Contracture  of  the  Tibialis  Posticus  in  the  Leg. — 
The  tendon  is  reached  as  described  for  the  flexor  longus  digitorum  pos- 
terior to  the  malleolus,  or  it  may  be  tenotomized  in  the  foot  below  the 
malleolus.  This  operation  is  almost  never  required  excepting  in  spastic 
paralysis  with  extreme  deformity. 

138.  Tenotomy  or  Tendon  Lengthening  of  the  Peroneii  Muscles. — 
In  the  case  of  the  peroneii  muscles,  it  is  better  if  cutting  them  subcuta- 
neously, to  select  a  point  a  little  forward  and  below  the  internal  mal- 
leolus. The  operator  strongly  adducts  the  foot,  feels  the  tendon  with 
the  forefinger  of  the  right  hand,  while  he  holds  the  tenotome  between 
the  thumb  and  forefinger  of  the  same  hand.  When  the  tenotomy  of  the 
peroneii  is  indicated  it  may  be  done  subcutaneously  as  in  elongating 
any  tendon  as  described  in  these  pages  under  tenotomy  of  the  tendo 
Achilles. 

If  the  tendons  are  to  be  tenotomized  back  of  the  internal  malleolus, 
a  small  incision  should  be  made;  the  tendons  lifted  out  on  a  blunt  dis- 
sector, or  director,  and  cut  across.  While  this  operation  is  desirable  in 
certain  spastic  conditions  and  some  cases  of  extreme  flat  foot  and 
may  be  found  necessary  in  certain  infantile  paralysis  cases,  it  is 
usually  better  to  transplant  these  muscles  if  they  are  strong  and 
make  them  useful  for  either  extending  or  flexing  the  foot,  depending 
on  which  motion  is  lacking.  Tendon  lengthening  should  be  done  in 
the  lower  middle  third  of  the  leg;  for  detail,  see  tendon  lengthening, 
section  127. 

139.  Tenotomy  or  Tendon  Lengthening  of  the  Tibialis  Anticus. — 
Tenotomy  of  the  tibialis  anticus  may  be  done  subcutaneously  at  the 
inner  side  of  the  foot  where  it  is  easily  felt  when  contracted.  Its  prom- 
inence may  be  exaggerated  by  abducting  and  pronating  the  foot.  It 
is  rarely  indicated 


128 


TECHNIQUE  OF  OPERATIONS 


The  rules  for  lengthening  the  tibialis  anticus  and  its  tenotomy  are 
the  same  as  those  described  in  these  pages  under  tenotomy  and  tendon 
lengthening. 

140.  Tenotomy  to  Relieve  Hammer  Toe  (see  Hammer  Toe  Oper- 
ation.   See  section  118  to  124). 

141.  Tenotomy  to  Relieve  Contracted  Extensor  Longus  Digitorum 
(see  Description  under  Hammer  Toe  Operation). 

142.  Subcutaneous  Tenotomy  of  Extensor  Longus  Digitorum  near 
the  Head  of  the  Metatarsal  (see  Description  made  under  Hammer 
Toe.    Section  118  to  124). 

143.  Different  Forms  of  Tenotomy  to  Relieve  Contracted  Extensor 
Longus  Digitorum  in  the  Lower  Leg  (see  Description  under  Hammer 
Toe  Operation  118  to  124.) 

144.  Operation  for  Tendon  Shortening. — A  tendon  may  be  short- 
ened in  many  different  ways.     A  tendon  extending  into  a  muscle  is 

shortened  over  the  belly  of  the  muscle  (see  figure  213, 
214),  or  the  tendon  may  be 
shortened  below  the  muscle 
(see  figures  217,  218). 

Two  incisions  are  made  across 
the  tendon  at  right  angles  to 
its  fibers  and  one  and  one-half 
inches  apart,  extending  halfway 
through,  one  on  the  inner  side 
\  I  \    -'/  and  one  on  the  outer  side  of 

[f  vH1/  ^e  tendon.     A  third  incision 

connects  these  two  by  splitting 
the  tendon  parallel  to  its  fibers 
(figure  213).  If  it  is  necessary 
to  shorten  the  tendon  a  quarter 
of  an  inch,  a  quarter  of  an 
inch  is  cut  away  from  the  end 
of  the  narrow  portion  of  each 
end,  as  shown  by  the  shaded 
marks  in  figure  217.  The  ten- 
don is  sutured  as  shown  in 
figure  218. 

145.  Other  Methods  of  Ten- 
don Shortening. — The  tendon 
may  be  overlapped  as  seen  in 
figure  216,  or  it  is  tucked  and  stitched  (see  figures  219  and  220),  or  it 
is  reefed  by  a  quilted  silk  suture  (see  figures  218  to  222).  When 
there  is  to  be  much  strain,  quilted  silk  sutures  as  suggested  by  Pro- 
fessor Lange  should  be  used  from  one  tendon  and  into  the  other  after 
whatever  method  of  shortening  used.  Additional  mattrass  sutures  may 
be  used  beside. 


Fig.  213.— Tendon 
shortening  in  the 
belly  of  the  muscle. 
Shaded  portion  is  re- 
moved and  the  space 
closed  as  shown  in 
figure  214. 


Fig.  214.  —  Ten- 
don shortening  su- 
tures in  place.  (See 
figure  213.) 


MUSCLE  AND  TENDON  OPERATIONS 


129 


146.  Operation  for  Shortening  the  Tendo  Achilles. — The  patient 
lies  face  downward,  the  feet  extend  beyond  the  end  of  the  operating 
table,  or  by  means  of  a  large  sand  bag  under  the  lower  third  of  the  tibia, 
the  foot  is  elevated  allowing  easy  motion  of  the  ankle  in  flexion  and  ex- 
tension without  touching  the  operating  table.  The  operator  stands  on 
the  same  side  as  the  foot  to  be  operated  on. 

An  incision  is  made  two  and  one-half  inches  long  parallel  to,  and  one- 
half  an  inch  to  the  side  of,  the  tendo  Achilles.  Dissection  is  made  in  one 
layer  down  to  the  tendo  Achilles  sheath.  Its  sheath  is  opened  longi- 
tudinally exposing  the  tendon.  This  is  cut  and  overlapped  (see  figures 
215  to  222),  or  tucked  and  stitched  or  reefed  by  quilted  silk  sutures. 
In  this  latter  instance,  the  tendon  shortens  to  the  tension  of  the  silk. 


Fig.    215.  — Cutting 
the  tendon. 


Fig.  216.— Slitting 
and  reefing  a  zigzag 
tenotomy.  The 
shortening  desired  is 
marked  in  shadow. 


Fig.  217.— Tendon 
shortened  and  su- 
tured, completed. 


Fig.  218.— Reefing 
with  quilted  sutures. 
Cutting  and  overlap- 
ping the  tendon. 


The  sheath  is  closed  by  small  catgut  sutures,  the  retracted  skin  and  fat 
allowed  to  slip  in  position  and  closed  by  interrupted  chromic  catgut 
sutures  number  00,  the  skin  with  continuous  chromic  catgut  sutures 
number  00.  Plenty  of  sheet  wadding  is  applied  over  a  very  small 
gauze  dry  dressing.  The  heel  is  protected  by  three  or  four  extra  thick- 
nesses of  sheet  wadding.  A  plaster  of  Paris  dressing  is  applied  snugly, 
holding  the  foot  in  an  equinus  position.  The  patient  is  allowed  to  walk 
on  the  foot  in  four  weeks  with  the  plaster  on  and  a  block  under  the  heel. 
In  seven  weeks  the  plaster  is  gradually  discarded. 

147.  Operation  for  Shortening  the  Extensor  Longus  Digitorum. — 
The  patient  lies  on  his  back,  the  operator  stands  on  the  side  of  the  leg 
to  be  operated  on. 

An  incision  is  made  two  inches  long,  through  the  skin  and  fat  over 
the  front  and  lower  third  of  the  leg.  The  skin  and  subcutaneous  fat 
are  retracted  exposing  the  extensor  tendons.     Lifting  each  tendon  on  a 


130 


TECHNIQUE  OF  OPERATIONS 


blunt   instrument   will   give   sufficient    pull   to   show    to  which   toe   it 
extends. 

Each  extensor  tendon  is  shortened  by  one  of  the  methods  described 
in  these  pages  under  Tendon  Shortening.     The  foot  is  put  up  in  plaster 


Fig.  219.  — Tuck- 
ing and  reefing,  slit- 
ting the  tendon  be- 
fore suture. 


Fig.  220.  — Tuck- 
ing and  reefing  with- 
out cutting  the  ten- 
don. 


Fig.  221.  —  Quilted 
suture  applied. 


in  marked  dorsal  flexion.  The  patient 
walks  for  two  weeks  with  the  plaster. 
After  six  weeks  the  plaster  is  discarded 
as  rapidly  as  possible. 

The  operation  is  necessary  only  in 
cases  with  contracture  of  the  flexors  or 
of  the  joint  that  has  existed  for  a  long 
time.  The  flexors  will  often  have  to  be 
lengthened  or  tenotomized. 

148.  Lange  Method.    Operation  for 
a  Weak  or  Paralyzed  Tibialis  Anticus. 
Transplantation  of  the  Peroneii  Mus- 
cles Forward  to  Give  Dorsal  Motion 
to  the  Foot. — The  patient  lies  on  his 
-Quilted  suture  reef  pulled  back,  a  sand  bag  under  the  ankle;  the 
operator  stands  on  the  same  side  of  the 
table  as  the  leg  to  be  operated  on.     A  rubber  bandage  is  applied  from 
the  toes  to  just  above  the  knee  where  a  tourniquet  is  applied  over  a 
towel.     The  leg  is  prepared  with  scrupulous  care  as  to  aseptic  detail. 

An  incision  is  made  one  inch  above  and  one-half  an  inch  posterior  to 
the  tip  of  the  external  malleolus  extending  upward  to  the  middle  of  the 
leg  parallel  to  the  fibula  (figure  223) .  An  incision  extending  around  the 
external  malleolus  and  close  to  the  bone  is  undesirable  as  the  scar  is 
sometimes  painful  to  the  patient  later  on.     The  strong  fibrinous  sheath 


Fig.  222.- 


MUSCLE  AND  TENDON  OPERATIONS 


131 


and  rectaculum  about  the  malleolus  should  not  be  opened  or  cut.  In 
this  way  the  joint  will  not  be  weakened  unnecessarily.  The  incision  is 
carried  down  to  the  peronei  muscles  which  should  be  examined  before 
transplanting.  If  red  they  will  be  vigorous  and  very  good  for  trans- 
planting, if  pink  they  will 
not  be  quite  as  serviceable, 
if  gray  or  grayish  pink  they 
will  not  be  useful  for  trans- 
plantation. The  lower  end 
of  the  incision  is  pulled 
downward  by  a  hooked 
retractor,  allowing  access 
to  the  tendons  below  the 
incisions  (figure  224) .    Fre-     FlG"  223--Illcisiotl  f or  reachinS  the  peroneii  muscles. 

quently  both  the  long 
and  short  peronei  are 
transplanted  at  the  same 
time.  They  are  cut  be- 
low as  shown  in  fig- 
ure 225,  the  detached 
ends  held  in  a  heme- 
static.  The  clamped  tip 
is  cut  away  later.  The 
operator  dissects  the 
muscles  from  the  bone 
with  a  scapel  until  a 
good  line  of  cleavage  is 
reached,  then  he  may 
continue  the  dissecting,  using  a  sponge.  He  should  avoid  injuring 
the  branch  from  the  external  popliteal  nerve  which  lies  near  the  bone 


Fig.  224. — Retraction  of  wound  below,  exposing  peroneii 
tendons,  below  the  incision. 


Fig.  225. — Cutting  the  peroneii  tendons. 

anterior  to  these  muscles  and  is  apt  to  be  rolled  up  in  the  separated 
muscle  sheath  as  it  folds  over  it.  Next  an  incision  two  inches  long  is 
made  over  the  anterior  and  middle  aspect  of  the  leg  down  to  the  fibers 
of  the  tibialis  anticus.     A  subcutaneous  tunnel  is  made  under  the  fat 


132 


TECHNIQUE  OF  OPERATIONS 


connecting  this  incision  with  the  upper  end  of  the  first,  a  long  clamp  or 
tendon  carrier  is  passed  through  the  tunnel  backward  grasping  the 
peronei  tendons,  bringing  them  forward  as  shown  in  figure  226.    Sterile 


Fig.  226. — Pulling  the  peronei  tendons  forward  out  through  the  anterior 

incision. 

towels  are  placed  above  and  below  this  mus- 
cle as  it  protrudes  through  the  anterior  in- 
cisions while  heavy  number  eighteen  silk  is 
quilted  up  one  side  of  the  tendon  and  down 
the  other  side  as  shown  in  figure  227. 
The  silk  should  be  pulled  and  tested  to  see 
that  it  is  strong  before  inserting  it  into  the 
tendon.  The  tendon  quilting  should  be  done 
very  carefully.  The  needle  is  passed  vertically 
through  the  tendon  as  shown  in  figure  227  in 
order  not  to  tear  the  tendon  fibers.  The  nee- 
dle is  not  inserted  twice  in  exactly  the  same  line 
as  this  favors  splitting  of  the  tendon.  About 
eight  stitches  should  be  made  in  this  way  on 
either  side  of  the  tendon. 

The  muscle  and  silk  are  now  turned  upward 
and  covered  with  a  sterile  towel  while  the  tun- 
nel is  made  in  or  under  the  subcutaneous  fat 
down  to  the  midtarsus  region.  The  point  of 
insertion  in  the  tarsus  is  determined  by  the  de- 
Fig.    227.  —  Method    of  formity  and  the  unparalyzed  muscles  remaining. 

quilting  the  silk  into  the  ten-    „,.  {■,».■,        .  ,       ,     i  i  j  ,1 

don,  and  method  of  placing  The  pull  of  the  transplanted  muscle  and  those 
needle  at  right  angles  to  the  remaining  should  bring  the  foot  up  with  an 
thedsUk.fibreS  WhGn  inserting  even  degree  of  pronation  and  supination.  If 
the  tibialis  anticus  is  paralyzed,  the  insertion 
is  placed  about  the  middle  of  the  midtarsus.  If  this  muscle  is  present 
to  a  slight  degree,  insertion  may  be  placed  further  to  the  outer  side. 


MUSCLE  AND  TENDON  OPERATIONS  133 

The  point  of  insertion  having  been  selected,  a  curved  flap  is  made  80 
that  its  base  overlies  (see  figure  226)  the  point  at  which  the  silk 
is  to  be  inserted.  The  flap  should  take  with  it  in  one  layer,  the  sub- 
cutaneous fat  and  fascia.  It  should  be  slightly  curved  and  laid  out 
not  to  cut  off  the  circulation  at  its  proximal  end.  By  means  of  a 
tendon  carrier  (figure  228),  a  tunnel  is  made  in  the  subcutaneous 


Fig.  228. — Tunnel  from  the  foot  to  the  anterior  leg  incision  method  of 
retracting  the  lower  end  of  the  anterior  leg  incision  to  prevent  inversion 
of  the  subcutaneous  tissues  while  drawing  the  muscle  downward. 

fat  connecting  the  anterior  leg  incision  with  the  foot  incision.  A  long 
tendon  carrier  (see  figure  230)  is  passed  from  the  foot  incision  up- 
ward, or  the  reverse;  the  silk  is  threaded  in  the  eye  of  the  carrier. 
The  lower  end  of  the  incision  on  the  front  of  the  leg  is  held  raised  by 
means  of  a  retractor  as  shown  in  figure  228  to  prevent  inversion  of  the 
fat  while  the  muscles  and  tendons  are  drawn  downward.     If  the  trans- 


Fig.  229. — Quilting  of  the  silk  tendon  extension  into  the  periosteum  of  the 

tarsus. 

plantation  is  done  in  an  adult  with  very  long  legs,  it  is  sometimes  neces- 
sary to  have  an  opening  in  the  front  of  the  leg  halfway  between  the 
upper  incision  and  the  foot.  The  silk,  the  tendon  and  muscle  are  then 
pulled  down  to  this  incision  and  then  to  the  foot.  The  silk,  the 
tendon  and  muscle  are  drawn  through  the  tunnel  and  the  silk  pro- 
trudes at  the  tarsal  incision  as  shown  in  figures  228  and  229.      The 


131 


Tl '(  UNIQUE  OF  OPERATIONS 


0 


silk  is  next  inserted  into  the  periosteum  of  the  tarsus  by  quilted  su- 
tures (see  figures  231,  232,  281).  The  operator  is  careful  that  the 
part  of  the  silk  in  the  eye  of  the  needle  or  any 
part  clamped  is  the  part  to  be  cut  away  later.  The 
silk  to  remain  in  the  patient  should  not  be  clamped 
'  nor  put  through  the  eye  of  the  needle.  Before  tying, 
each  strand  is  pulled  upon  so  that  it  will  be  tense, 
holding  the  foot  in  a  position  of  slight  dorsal  flexion. 
The  operator  should  assure  himself  that  the  muscle 
is  not  caught  at  any  one  point  in  the  tunnel  and  that 
it  will  slide  freely  as  far  as  it  will,  before  inserting  the 
silk  into  the  periosteum  of  the  foot,  otherwise  there 
may  be  relaxation  of  the  silk  during  convalescence. 
When  the  silk  is  tied,  it  should 
hold  the  foot  above  the  desired 
position.  After  being  tied  three 
times,  the  knot  is  pressed  into 
fVWl 


U 


/ 


Fig.  231.  — Needle  and 
silk  being  inserted  into  the 
periosteum. 


Fig.     232.  —  Silk    quilted 
into  the  periosteum. 


the  periosteum  so  that  it  will  lie  flat.     It  is  then 
covered  over  by  the  muscle  fibers  or  tendons  in  the 
foot.    The  deep  tis-        *^ 
sues     are     brought         "> 
together  with  inter- 
rupted chromic  cat- 
gut sutures  number 
00,     the     subcuta- 
neous fat  with  in- 
terrupted   -chromic 
catgut  sutures  num- 
ber 00,  the  skin  with 
continuous  chromic 
catgut  sutures  num- 
ber   00.      Six    layers        ^ig.  ^33. — Method  of  applying  force 
f  i         j    with  the  finger  close  to  the  needle,  while 

OI   gauze  are  placed    msertmg  the  needle  into  the  periosteum 
Over  each  WOUnd  ex-    or  bone  to  avoid  breaking  the  needle. 
Fig.  230.  -  Tendon    tending   One-half    No  Pressure  is  used  to  twist  the  handle 

D       ,        , ,        of  the  needle  holder. 

earner.  mc\1     beyond     the 

ends  of  incisions  and  about  one  inch  or  one  and  one-half  inches  broad. 
149.  Plaster  of  Paris. — This  size  dressing  facilitates  inspection  later 
on   without    interfering   with    the   plaster.     A   large   fold  or   roll   of 


MUSCLE  AND  TENDON  OPERATIONS 


135 


loose  sterile  sheet  wadding  is  placed  over  the  front  of  the  leg  to 
prevent  pressure  on  the  transplanted  muscle  (see  figures  234  to  235): 
over  this  sheet  wadding  rollers  are  placed  before  applying  the  plaster 
of  Paris  bandage.  The  plaster  of  Paris  bandage  should  reach  from 
the  toes  to  the  groin  with  the  foot  slightly  overcorrected,  relaxing 
the  tendon  and  silk.  The  plaster  is  split  on  each  side  allowing  the 
front  to  be  lifted  or  removed  for  inspection  of  the  dressing.  The 
foot  should  be  manipulated,  before  operating  so  that  its  action  is 
free  and  normal  in  all  directions.  If  the  tendo  Achilles  is  short  this 
must  be  relieved  before 
doing  any  transplantation 
to  the  front  of  the  foot. 
When  this  has  been  ac- 
complished then  a  tendon 
transplantation  may  be 
performed.  A  strong  ten- 
don Achilles  should  be 
tenotomized  when  muscles 
are  transplanted  to  the 
front  of  the  foot.     When       FlG  234   _Roll  of  sheet  wadding  applied  after  ten. 

there      IS      much      Swelling    don  transplantation  to  prevent  pressure  of  the  plaster 
after     the     Operation     the    over  the  transplanted  muscle. 

front  of  the  plaster  is 
raised  allowing  one-half 
inch  gap  on  both  sides  of 
the  plaster  from  the  toes 
to  the  upper  thigh.  If 
necessary  the  sheet  wad- 
ding roll  on  the  front  of 
the  leg  is  removed  and  the 

sheet  wadding   split  along    FlG-  235- — Sheet  wadding  rollers  being  applied  over 

the  whole  front  of  the  leg, 


the  large  sheet  wadding  roll. 

the    skin    from 
groin. 


exposing 

the  toes  to  the 
This  will  prevent  any  con- 
striction from  bands  of 
sheet  wadding.  This  need 
not  be  done  unless  there 
is  much  swelling.  There 
is  usually  considerable 
swelling    after    a    muscle 

Fig.  236. — bheet  wadding  rollers   applied  ready  for  . °  .  _  .„ 

plaster.  After  muscle  transplantation  the  whole  leg  and  transplantation.  It  Will 
foot  should  be  included  in  the  plaster.  be   very  much   less   if  the 

operator  handles  the  tissues  carefully  and  avoids  all  roughness  in 
the  manipulation  of  the  joints  and  transplanted  tissues.  Unnecessary 
roughness  is  especially  to  be  avoided  in    making  the  subcutaneous 


13G 


TECHNIQUE  OF  OPERATIONS 


tunnels.  The  incisions  may  be  inspected  on  the  fifth  or  seventh  or 
tenth  day  and  fresh  dressing  applied.  If  there  is  the  slightest  moisture, 
an  alcohol  dressing  is  applied  and  repeated  in  two  days;  after  that  the 
dressing  should  be  dry  (see  healing  of  wounds  in  infantile  cases  under 
general  consideration). 

150.  After  Treatment. — The  patient  should  be  encouraged  to 
move  as  little  as  possible  for  the  first  five  days;  pillows  are  allowed 
then,  raising  the  pal  lent  forty-five  degrees.  He  may  turn  on  his  side 
at  the  end  of  ten  days.      At  that  time  a  bed  rest  is  allowed.      The 

patient  is  kept  very  quiet 
for  six  weeks.  After  that 
he  is  allowed  to  be  in  a 
go-cart  or  in  a  wheel 
chair.  He  walks  with 
crutches  in  the  eighth 
week.  Weight-bearing 
with  the  plaster  is  allowed 
after    the    eighth    week. 

Fig  237.— A  method  of  splitting  a  plaster  of  Paris  yfam  walking  is  easy 
bandage;  webbing  straps  hold  the  plaster  together.     A        .  ,       ,  .       °  , 

plaster  to  the  groin  should  be  used  after  muscle  trans-    WltU   tUe  plaster,   a   Snort 

plantation.  caliper   is    used    with    a 

double  ankle  stop.  The 
braces  are  used  during  the 
day,  a  plaster  of  Paris  at 
night  holding  the  foot  at 
right  angles.  Special  exer- 
cises and  muscle  training 
are  started  the  seventh 
week  after  operation  and 
continued  for  a  year  at 
least.  Great  care  should 
be  taken  not  to  stretch  the 
foot  downward  for  about 
a  year.  The  shoe  and  stocking  should  be  removed  with  an  upward  and 
not  downward  pull.  Much  may  be  expected  from  the  transplantation  of 
the  peronei  muscles,  especially  when  they  are  red  and  large.  Great  care 
should  be  used  in  selecting  the  insertion  with  reference  to  the  deformity 
and  the  pull  of  the  muscles  that  will  exist  after  transplantation.  The 
peronei  or  any  other  muscle  should  not  be  transplanted  to  give  power 
to  raise  the  foot  without  doing  something  to  give  good  lateral  stability 
at  the  ankle  joint  if  this  is  flail  or  very  weak  (see  operations  for  flail 
ankle).  A  muscle  when  carefully  transplanted  will  give  strength  where 
it  is  placed  and  take  up  the  new  motion,  but  it  must  not  be  expected  to 
give  strength  and  lateral  stability  besides.  Any  joint  deficiency  must  be 
compensated  for  either  before  or  at  the  time  of  transplanting.  In  any 
transplantation,  one-half  of  the  lower  end  of  the  tendon  to  be  trans- 


Fig.  238. — Plaster  of  Paris  bandage,  split  and  held 
with  a  three  inch  gauze  bandage  wet  and  placed  at 
intervals. 


MUSCLE  AND  TENDON  OPERATIONS  137 

planted  may  be  left,  and  a  tendon  fixation  done  with  it  (see  Tendon 
Fixation). 

The  principles  for  joint  stability  considered  under  the  different  de- 
formities are  applicable  in  connection  with  the  various  transplantations. 
•  Sections  109  and  110.  Whenever  transplanting  a  muscle  or  tendon 
when  it  will  reach  the  bone,  it  can  be  placed  in  a  groove  under  the 
periosteum  as  recommended  by  Dr.  Vulpius.  When  it  will  not  reach, 
silk  elongation  is  most  satisfactory. 

151.  Operation  for  a  Weak  or  Paralyzed  Tibialis  Anticus.  Trans- 
plantation of  the  Tibialis  Posticus  Forward  to  give  Dorsal  Motion 
to  the  Foot. — The  patient  lies  on  his  back  with  his  leg  outwardly 
rotated,  a  sand  bag  or  heavy  pillow  may  be  placed  under  the  buttock 
of  the  opposite  side;  the  operator  stands  on  the  same  side  as  the  leg  to  be 
operated  on. 

OPERATION 

An  incision  is  made  parallel  to  the  tibia  extending  one  inch  above  and 
one-half  inch  posterior  to  the  internal  malleolus,  extending  up  to  the 
middle  of  the  leg  and  down  to  the  muscle  layer.  The  tibialis  posticus 
tendon  is  lifted  on  a  blunt  dissector.  It  may  be  distinguished  from  the 
long  flexor  of  the  toe  as  the  latter  will  contract  the  toes  when  forcibly 
lifted  on  the  blunt  dissector.  An  assistant  holds  the  incision  retracted 
downward  while  the  tibialis  posticus  tendon  is  drawn  up  and  cut  away 
below.  The  tendon  tip  is  held  in  the  hemastatic,  the  compressed  part  is 
cut  away  later.  The  tendon  and  muscle  are  dissected  up  to  the  middle 
of  the  leg.  An  incision  is  made  over  the  front  and  middle  of  the  tibia, 
a  tunnel  is  made  from  the  upper  end  of  the  first  incision  subcutaneously 
to  the  incision  on  the  anterior  part  of  the  leg.  A  tendon  carrier  or  long 
clamp  is  passed  from  the  anterior  incision  backward,  grasps  the  tip  of 
the  tibialis  posticus  tendon,  draws  it  forward  followed  by  its  muscle. 
Sterile  towels  are  placed  above  and  below  the  muscle,  while  silk  is  quilted 
up  one  side  and  down  the  other  side  as  shown  in  figure  227.  In  in- 
serting the  needle  through  the  tendon  it  should  be  passed  vertically 
through  in  order  not  to  tear  the  fibers  as  shown  in  figure  227.  The 
muscle  and  silk  are  turned  upward  and  covered  with  a  sterile  towel  while 
a  tunnel  is  made  in  or  under  the  subcutaneous  fat  down  to  the  mid- 
tarsus  region.  The  point  of  insertion  in  the  midtarsus  is  determined  by 
the  unparalyzed  muscles  remaining.  If  the  tibialis  anticus  is  paratyzed, 
the  insertion  may  be  made  about  the  middle  of  the  midtarsus  at  B, 
figure  247.  If  this  muscle  is  present  to  a  slight  degree,  insertion  may 
be  made  further  to  the  outer  side  (C,  figure  247).  The  point  of  insertion 
having  been  selected,  a  curved  flap  is  made  so  that  its  base  overlies  the 
point  at  which  the  silk  is  to  be  inserted  (figure  226).  The  flap  should 
take  with  it  in  one  layer  the  subcutaneous  fat  and  fascia  and  extend  to 
the  layer  of  the  tendons  and  muscles.  Its  curve  should  be  slight  and 
laid  out  not  to  cut  off  the  circulation  at  its  proximal  end.     A  subcuta- 


138  TECHNIQUE  OF  OPERATIONS 

neous  tunnel  is  made  by  means  of  a  tendon  carrier  (see  figure  230), 
from  the  incision  at  the  front  of  the  leg  to  the  incision  in  the  foot.  The 
lower  end  of  the  upper  incision  is  carefully  held  up  by  means  of  a  retrac- 
tor (figure  228)  to  prevent  inversion  of  the  fat  while  the  muscles  and 
tendons  are  drawn  downward.  The  muscle  is  drawn  through  the 
tunnel  and  the  silk  protrudes  through  the  incision  at  the  tarsus  as  shown 
in  figure  229.  The  silk  is  quilted  in  the  periosteum  as  shown  in 
figures  231  and  232.  Before  tying,  each  strand  is  pulled  upon  so  that 
it  will  be  tense,  holding  the  foot  in  a  position  of  very  slight  dorsal 
flexion.  The  operator  should  assure  himself  that  the  muscle  is  not 
caught  at  any  one  point  in  the  tunnel  and  that  it  will  slide  freely  as  far 
as  it  will  go  before  inserting  the  silk  in  the  periosteum  of  the  foot, 
otherwise  there  may  be  relaxation  of  the  silk  during  the  convalescence. 
When  the  silk  is  tied  the  foot  should  be  held  in  the  desired  position  in 
slight  dorsal  flexion.  After  being  tied  the  knot  is  pressed  flat  and 
covered  over  by  the  muscle  fibers  or  tendons  in  the  foot,  then  the  deep 
tissues  are  brought  together  with  interrupted  chromic  catgut  sutures 
number  00,  the  subcutaneous  fat  with  interrupted  chromic  sutures 
number  00,  and  the  skin  with  continuous  chromic  catgut  sutures  num- 
ber 00.  Six  layers  of  gauze  are  placed  over  each  wound  extending  one- 
half  inch  beyond  the  ends  of  incision  and  about  one  inch  or  one  and  one- 
half  inches  broad.  This  size  dressing  facilitates  the  inspection  of  the 
wound  later  on  without  interfering  with  the  plaster.  Sterile  sheet 
wadding  should  be  applied  with  a  large  fold  or  roll  of  loose  sheet  wadding 
over  the  front  of  the  leg  to  prevent  pressure  from  the  plaster  on  the 
transplanted  muscle  (see  figures  234  to  236) .  After  this  sheet  wadding 
rollers  are  applied;  a  plaster  of  Paris  bandage  is  next  applied  from  the 
toes  to  the  groin  with  the  foot  slightly  overcorrected,  relaxing  the 
tendon  and  silk. 

Before  operation  for  transplantation  forward  at  the  ankle,  if  the 
tendo  Achilles  is  extremely  strong  it  is  well  to  do  a  tenotomy.  The  foot 
should  be  manipulated  so  that  its  action  is  free  and  normal  in  all  direc- 
tions. When  this  has  been  accomplished  a  tendon  transplantation  may 
be  performed.  The  after  care  in  this  operation  is  the  same  as  that  laid 
down  for  transplantation  of  the  peronei  muscles  forward. 

In  using  the  tibialis  posticus  for  transplantation  it  may  be  well  to  slit 
the  tendon  longitudinally  and  take  half  of  the  tendon  with  the  whole 
muscle  for  transplantation  as  described  above.  The  half  of  the  tendon 
remaining  attached  below  can  be  used  to  fix  the  joint  as  described  under 
tendon  fixation.  This  will  prevent  pronation  and  weakening  of  the 
joint  laterally.  The  rules  that  govern  joint  stability  should  be  observed 
as  described  under  transplantation  of  the  peronei  muscles  and  as  de- 
scribed under  the  various  foot  deformities.     Sections  109  and  110. 

152.  Operation  for  a  Weak  or  Paralyzed  Tibialis  Anticus.  Trans- 
plantation of  the  Flexor  Longus  Digitorum  to  Give  Dorsal  Motion  to 
the  Foot. — This  operation  differs  in  no  way  from  the  transplantation 


MUSCLE  AND  TENDON  OPERATIONS 


139 


of  the  tibialis  posticus  forward  excepting  in  the  use  of  the  long  flexor 
of  the  toes  instead  of  the  tibialis  posticus.  The  operative  consideration 
and  the  after  care  are  the  same. 

153.  Operation  for  a  Weak  or  Paralyzed  Tibialis  Anticus.  Trans- 
ferring the  Extensor  Longus  Hallucis  to  Re-enforce  the  Tibialis  An- 
ticus in  the  Lower  Third  of  the  Leg. — The  patient  lies  on  his  back, 
the  operator  stands  on  the  side  of  the  leg  to  be  operated  on. 

An  incision  is  made  two  inches  long  through  the  skin  and  fat  over  the 
front  and  lower  third  of  the  leg.  The  skin  and  subcutaneous  fat  are  re- 
tracted and  the  extensor  tendons  are  exposed.    Lifting  each  tendon  on  a 


Fig.  239.— Expos- 
ure of  the  tibialis 
anticus  and  extensor 
longus  hallucis  in  the 
lower  third  of  the 
leg. 


Fig.  240.— The  ex- 
tensor longus  hallu- 
cis transferred  to  re- 
enforce  the  tibialis 
anticus  in  the  lower 
third  of  the  leg.  (See 
figure  239.) 


Fig.  241.— The  ex- 
tensor longus  hallu- 
cis sutured  after 
being  transferred  to> 
the  tibialis  anticus. 


blunt  instrument  will  give  sufficient  pull  to  show  to  which  toe  it  extends. 
The  extensor  of  the  great  toe  is  isolated  and  cut,  the  proximal  end  is 
placed  through  a  slit  in  the  tibialis  anticus  tendon  and  pulled  into  the 
slit  until  it  relaxes,  the  tibialis  muscle  slightly  above  the  slit.  Quilted 
sutures  are  then  used  to  unite  both  tendons;  either  mattrass  sutures  or 
quilted  sutures  are  used  (see  figures  239  to  241).  The  wound  is  closed 
up  in  slight  dorsal  flexion,  relieving  the  strain  on  the  transplanted 
muscle.  After  six  weeks  the  patient  walks  for  two  weeks  with  the  plaster, 
after  that  it  is  removed  gradually.  When  the  tibialis  anticus  is  nearly 
completely  paralyzed,  a  short  caliper  brace  with  a  double  stop  at  the 
ankle  is  worn  for  about  a  year  during  the  day  and  a  plaster  or  posterior 
wire  splint  is  worn  at  night.    The  latter  reaches  from  the  toes  to  below 


140 


TECHNIQUE  OF  OPERATIONS 


the  knee.     Muscle  training  and  special  exercise  should  be  done  for  a 
year  or  more. 

154.  Operation  for  Transplantation  of  the  Extensor  Longus  Hallucis 
to  the  Tarsus  for  Weak  or  Paralyzed  Tibialis  Anticus. — A  transplanta- 
tion of  the  extensor  longus  hallucis  may  be  done  to  the  tarsus,  to  the 
metatarsal  or  in  the  lower  third  of  the  leg  to  the  tibialis  anticus.  This 
operation  is  often  done  in  addition  to  transplanting  other  muscles  such 
as  the  peroneii  forward.  Besides  giving  added  power  to  raise  the  foot, 
it  will  decrease  the  tendency  to  hammer  toe  when  this  is  developing. 


Fig.  242. — Incision 
on  the  dorsum  of  the 
foot  exposing  the  ex- 
tensor tendons. 


Fig.  243.  —  Silk 
quilted  into  the  ex- 
tensor longus  hallucis 
which  is  ready  to  be 
placed  into  the  slit 
tibialis  anticus  ten- 
don. 


Fig.  244.  —  Inser- 
tion of  the  extensor 
longus  hallucis  into 
the  slit  tibialis  anti- 
cus tendon. 


Operation  for  a  Weak  or  Paralyzed  Tibialis  Anticus.  Transplant- 
ation of  the  Extensor  Longus  Hallucis  to  the  Tendon  in  the  Foot. 
— An  incision  is  made  over  dorsum  of  the  foot,  the  tendon  is  cut  away 
from  the  toe  at  the  dorsum  of  the  foot,  silk  is  quilted  up  one  side  and 
down  the  other  of  the  tendon  and  the  tendon  fastened  into  the  perios- 
teum of  the  bone  by  means  of  this  silk  which  is  quilted  into  the  perios- 
teum (see  figures  242  to  244).  The  operative  technique,  the  operative 
considerations,  and  the  after  treatment  are  all  similar  to  that  considered 
under  transplantation  of  the  peroneii  forward  and  under  deformities 
of  the  foot  and  ankle.     Sections  151,  109,  110. 

155.  Transplantation  of  the  Extensor  Longus  Digitorum  to  the 
Tarsus  to  Raise  the  Foot;  for  a  Weak  or  Paralyzed  Tibialis  Anticus.— 
The  patient  lies  on  his  back,  the  operator  stands  on  the  same  side  as  the 
leg  to  be  operated  on,  a  sand  bag  is  placed  under  the  ankle. 

A  longitudinal  incision  is  made  over  the  dorsum  of  the  foot  from  the 
base  of  the  third  metatarsal  to  the  annular  ligament  (figure  258).  The 
extensor  tendons  of  the  four  outer  toes  are  cut  away  as  low  down  as 
possible.  The  foot  is  brought  up  to  a  dorsal  position  twenty  degrees 
from  a  right  angle.  The  tendons  are  cut  long  enough  so  that  when 
attached  to  the  periosteum  of  the  tarsal  bones  they  will  hold  the  foot 


MUSCLE  AND  TENDON  OPERATIONS 


141 


in  position.  The  silk  is  quilted  up  one  side  and  down  the  other  side  of 
the  tendons  as  shown  in  figure  227.  This  quilting  must  be  done  high 
on  the  tendons  as  the  operator  will  see.  This  may  be  done  in  pairs  or 
all  four  tendons  may  be  quilted  at  the  same  time.  The  lower  end  of  the 
silk  is  quilted  into  the  periosteum  overlying  the  tarsal  bones  (see  figure 
232).  The  point  selected  for  the  insertion  of  this  silk  into  the  tarsus 
will  depend  largely  on  the  deformity  and  the  muscles  that  are  paralyzed 
(see  General  Considerations  in  Muscle  Transplantation  and  Foot  De- 
formities). Sections  109,  110.  If  the  tibialis  posticus  is  strong,  these 
tendons  may  be  transplanted  outward  to  re-enforce  the  action  of 
the  peroneii  muscles.     If  the  tibialis  anticus  is  paralyzed,  and  the 


Fig.  245.  —  Inser- 
tion of  quilted  silk 
sutures  into  the  cut 
tendons  of  the  tibia- 
lis anticus  and  the 
extensor  longus  hal- 
lucis. 


Fig.  246. —  Inser- 
tion of  the  tendons 
by  quilted  silk  su- 
tures into  the  perios- 
teum at  the  middle 
of  the  tarsus. 


Fig.  247.— Points  of 
insertion  in  the  tarsus 
for  tendons  or  silk  liga- 
ments. 


tibialis  posticus  is  gone,  these  tendons  should  be 
transplanted  to  the  inner  side  of  the  foot  to  raise 
the  foot  (see  figures  245-246)  and  counter-balance  the  peroneii  muscles. 
If  the  peroneii  and  tibialis  anticus  and  tibialis  posticus  are  all  gone,  it 
will  be  of  advantage  to  attach  these  tendons  in  the  middle  of  the  foot 
or  to  place  two  to  the  outer  side  and  two  to  the  inner  side.  The  me- 
chanical action  of  the  foot  before  transplantation  should  be  observed 
and  also  the  relative  strength  of  the  muscles  to  be  transferred. 

The  operative  consideration  and  after  treatment  are  similar  to  that 
described  for  transplantation  of  the  peroneii  forward.  If  the  tendo 
Achilles  is  short,  this  must  be  relieved  before  any  transplantation  to  the 
front  of  the  foot. 

156.  Operation  for  a  Weak  or  Paralyzed  Tibialis  Anticus.  Trans- 
plantation of  the  Extensor  Longus  Digitorum  to  the  Tibialis  Anticus 
in  the  Lower  Third  of  the  Leg. — The  extensor  longus  digitorum  may 
be  transplanted  to  the  tibialis  anticus  tendon.  An  incision  two  and  one- 
half  inches  long  is  made  on  the  anterior  aspect  of  the  lower  third  of  the 
tibia  and  parallel  to  it. 


142 


TECHNIQUE  OF  OPERATIONS 


The  extensor  tendons  are  drawn  up  and  cut  away  below.    A  slit  is 
made  in  the  tibialis  anticus  tendon. 

The  detail  of  this  operation  and  the  after  treatment  is  the  same  as  that 
described  for  the  transplantation  of  the  extensor  longus  hallucis  into 
the  tendon  of  the  tibialis  anticus.    See  section  153. 

157.  Transplantation  of  the  Extensor  Longus  Hal- 
lucis to  the  Head  of  the  Metatarsal. — This  may  be 
done  by  an  incision  over  the  dorsum  of  the  foot  two 
inches  long  extending  from  the  joint  upward.  The 
dissection  is  carried  down  to  the  tendon,  the  incision  is 
stretched  downward  by  retractors  and  the  tendon  cut 
away  below.    As  it  is  held  up  it  is  slit  with  a  tenotome 


Fig.  248.  —  The 
extensor  longus  hal- 
lucis transferred  to 
re-enforce  the  long 
extensor  tendons  of 
the  toes. 


Fig.  251.  —  Split 
tendon  passed 
through  the  bone. 
The  second  silk 
wormgut  leader 
ready  to  carry  the 
other  end  of  the  ten- 
don through  the 
bone  in  the  opposite 
direction. 


Fig.  249.— Drilling  the 
head  of  the  metatarsal; 
cut  and  split  extensor 
tendon.  (Silk  wormgut 
leader  doubled  and  placed 
in  the  drill  end). 


Fig.  252.  —  Both 
ends  of  the  split  ten- 
don passed  through 
the  bone. 


Fig.  250.— Two  silk 
wormgut  leaders,  one 
looped  into  the  first 
which  protrudes 
through  the  drill  hole 
in  the  bone.  Slit 
tendon  ready  to  be 
pulled  through  the 
bone. 


Fig.  253. — Suture 
of  the  tendon  ends  to 
the  unsplit  portion  of 
the  tendon. 


(figure  249).    The  head  of  the  metatarsal  is  drilled  in  its  end.     The  two 
ends  of  a  piece  of  silk  wormgut  are  threaded  through  this  hole  (see 


MUSCLE  AND  TENDON  OPERATIONS 


143 


figure  250),  and  drawn  through  the  bone.  The  loop  acts  as  a  leader 
to  draw  the  split  tendon  through  the  bone  (figure  251).  The  operator 
should  be  careful  to  use  a  large  size  drill  in  order  that  the  hole  will 
be  large  enough  to  allow  the  tendon  to  be  drawn  through  easily. 
A  second  loop  of  silk  wormgut  is  passed  through  the  first  loop  and 
drawn  through  the  bone  with  one  end  of  the  slit  tendon  (figure  250). 
As  the  end  of  the  tendon  emerges  from  the  other  side  of  the  bone  it 
is  grasped  at  its  end  by  a  small  hemastatic  and  pulled  tightly.  The 
clamped  tip  is  cut  away  later.  The  projecting  loop  of  silk  wormgut 
which  has  just  been  pulled  through  with  the  tendon  is  now  ready  to 
receive  the  other  end  of  the  slit  tendon  (see  figure  251). 

This  end  is  pulled  through  the  bone  in  an  opposite  direction  from  its 
fellow  (see  figure  252). 

An  assistant  holds  the  foot  in  dorsal  flexion  during  the  application 
of  the  tendon  to  the  bone.     The  two  tendon  ends  are  drawn  tight  and 


Fig.     2  5  4. —  A 

method   of    suturing  Fig.  255.— Method  ,    *IG-    ^5fcV~Tu         £ 

the    tendon    to    the  of  using  silk  sutures  loop  passed  through 

capsule    and   perios-  to  hold  the  split  ten-  *he  hfad  of  the  metua" 

teum  with  silk.  don.  *arsal     recflves     *he 

tendon;    it    is    then 

folded  over  the  dorsum  of  the  metatarsus  where  they  turned  over  and  su- 
meet  (see  figure  253) ,  and  are  sutured  together  with  *"e6257 )  ' 
interrupted  chromic  catgut  sutures  number  00  and 
at  the  same  time  sutured  to  the  tendon  from  which  they  come  above 
its  division  (see  figure  253).  The  deep  tissues  are  brought  together 
over  them  with  interrupted  chromic  catgut  sutures  number  00,  the 
subcutaneous  fat  with  interrupted  chromic  catgut  sutures  number 
00,  the  skin  with  continuous  chromic  catgut  sutures  number  00. 
Other  methods  of  suture  are  suggested  in  figures  254,  255,  257.  In 
judging  the  tension  on  the  tendon  of  the  transplanted  extensor  hallucis, 
the  operator  should  see  that  it  maintains  the  foot  at  a  right  angle  before 
the  sutures  are  placed.  A  plaster  well  padded  with  sheet  wadding  is 
applied  from  the  toes  to  the  knee.  The  patient  is  allowed  to  walk 
with  the  plaster  at  the  end  of  the  third  week  if  no  other  operation 
has  been  done.  The  muscles  should  be  trained  and  exercised.  The 
after  care  otherwise  is  the  same  as  that  for  transplantation  of  the 
peroneii. 


144 


TECHNIQUE  OF  OPERATIONS 


158.  Transplantation  of  the  Extensor  Longus  Digitorum  in  Paralysis 
of  the  Tibialis  Anticus  or  when  the  Tibialis  Anticus  is  very  Weak. — 
The  extensor  longus  digitorum  is  very  useful  for  transplantation  to  give 
power  to  raise  the  foot  when  the  tibialis  anticus  is  weak  or  paralyzed. 
This  transplantation  may  be  used  in  addition  to  other 


A 


Fig.  257.— Suture 
of  the  tendon  passed 
over  the  silk  loop. 
(See  figure  250.) 


transplantations  of  muscles  placed  forward,  especially 

Owhen  these  muscles  are  strong  and  are  causing  de- 
formity. When  the  patient  is  raising  the  foot  largely 
by  the  power  of  the  external  longus  digitorum  as  is 
often  the  case  in  paralysis  of  the  tibialis  anticus,  and 
other  paralyses,  a  hammer  toe  and  claw  foot  is  de- 
veloping either  from  the  strong  action  of  the  long 
extensors  of  the  toes  or  from  the  weak  opponents  or 
both.  In  this  instance  a  transplantation  is  doubly 
useful.  The  tendons  may  be  transplanted  to  the 
tarsus  altogether  or  in  pairs,  they  may  be  transplanted 
to  the  head  of  the  metatarsals  or  they  may  be  inserted 

into  the  tibialis  anticus  tendon  in  the  lower  third 

of  the  leg.     The  consideration  of  the  insertion  of 

transplanted  tendons  is  discussed  separately  (see 

sections  109,  110)  under  transplantation  of  the 

peroneii  and  under  the  various  deformities  of  the 

ankle  and  foot  (see  also  Hammer  Toe,  sections 

118  to  124).     Persistent  extension  of  the  toes 

gives    a    permanent   deformity,   and    causes   a 

callous  under  the  ball  of  the  toes  sooner  or  later. 

159.  Transplantation  of  the  Extensor  Longus 
Digitorum  to  the  Head  of  the  Metatarsal  to  give 
Power  to  Raise  the  Foot. — The  extensor  longus 
digitorum  tendons  may  each  be  put  into  the 
head  of  its  metatarsals  as  already  described  for 
the  extensor  longus  hallucis.    Section  158. 

The  after  treatment  is  the  same  as  for  trans- 
plantation of  the  peroneii  muscles  forward. 

160.  Operation  for  Paralysis  of  the  Tibialis 
Anticus.    Transplantation  of   One-half  of  the 
Tendo    Achilles    Forward. — One-half    of    the  of  the  foot.     1.  Extensor 
tendo  Achilles  may  be  brought  forward  with  brevis.  2.  Extensor  longus. 

,     1(.     «  ..  t  i   ,  i       ,    j  .    ,      ,r       3.  Extensor      hallucis. 

one-halt  of  its  muscle  and  transplanted  into  the  4_  Tibialis  anticus.  A,  B, 
tibialis  anticus  tendon  or  into  the  tarsus  as  de-  and  C  are  good  points  for 
scribed  for  the  tibialis  posticus  forward.     With  the  silk  insertion,  under  the 

.  c  .  ,         .  muscles,  whenever  possible. 

this  operation  a  tendon  fixation  may  be  done 

with  one-half  of  the  tibialis  anticus  and  one-half  of  the  tibialis  posticus. 
The  after  treatment  is  the  same  as  for  transplantation  of  the  tibialis 
posticus  forward. 


MUSCLE  AND  TENDON  OPERATIONS  145 

161.  Operation  for  Partial  or  Total  Paralysis  of  the  Peroneii.  Trans- 
plantation of  one-half  of  the  Tendo  Achilles  Forward. — When  the 
peroneii  are  paralyzed  or  very  weak  and  there  is  no  other  better  procedure 
to  restore  the  usefulness  of  the  foot,  if  the  tendo  Achilles  is  extremely 
strong,  this  tendon  may  be  slit  upward  from  the  os-calcis  and  one-half 
of  the  tendon  and  muscle  transplanted  forward. 

An  incision  is  made  one-half  way  between  the  external  malleolus  and 
the  outer  edge  of  the  tendo  Achilles  extending  upward  to  the  middle  of 
the  leg.  The  incision  is  dissected  up  and  retracted  exposing  the  tendo 
Achilles  and  its  muscle  and  the  peroneii  tendons  with  their  muscles. 
The  outer  half  of  the  Achilles  tendon  is  cut  away  below  at  the  os-calcis 
and  dissected  up  and  carried  forward  and  attached  to  the  peroneii  ten- 
dons, as  follows;  the  tendon  is  drawn  down  along  the  peroneii  and  in- 
serted through  the  slit  made  in  the  peroneii;  a  silk  suture  is  first  quilted 
into  the  half  Achilles  tendon.  This  silk  is  quilted  into  the  peroneii 
tendons  holding  the  foot  in  slight  equinus  valgus.  The  deep  sutures 
are  brought  together  with  interrupted  chromic  catgut  sutures  number  00, 
the  subcutaneous  fat  with  interrupted  chromic  catgut  sutures  number  00, 
the  skin  with  continuous  chromic  catgut  sutures  number  00.  A  plaster 
of  Paris  bandage  is  applied  from  the  toes  to  the  groin. 

In  selected  cases  this  procedure  will  correct  a  slight  varus  and  give 
power  to  abduct  the  foot.  The  after  treatment  is  the  same  as  prescribed 
for  transplantation  of  the  peroneii  forward,  excepting  that  the  foot  is 
put  up  in  an  equino  valgus  and  held  there  by  a  plaster  for  six  weeks, 
later  a  brace  is  used  and 
the  heel  and  shoe  built  up 
to  maintain  this  position 
for  about  six  months.  After 
that  the  foot  is  put  up  in 
this  extreme  position  a 
short  time  each  day. 

162.  Operation  for  Total 
or  Partial  Paralysis  of  the 
Tibialis  Posticus.  Trans- 
plantation of  one-half  of 
the  Tendo  Achilles. — One- 
half  of  the  tendo  Achilles  is 
transplanted  forward,  into 
the  tibialis   posticus,  done    .  FlG-  259-  —  Inci- 

on  the  inner  side  of  the  leg    bXeeTthf  tendo  F^T260.-The    , 

as    described    for    paralysis    Achilles      and      the  neii  muscles  dissected  up 

of  the  peroneii  tendons.  peroneii  tendons.  and  quilted  with  silk. 

The  post  operative  treatment  is  the  same ;  the  foot,  however,  should  be 
put  up  in  a  position  of  equino  varus.  With  this  operation  one-half  of 
the  tibialis  posticus  may  be  attached  to  the  internal  malleolus  (see 
Tendon  Fixation  for  Valgus). 


146  TECHNIQUE  OF  OPERATIONS 

163.  Operation  for  Transplantation  of  the  Flexor  Longus  Digitorum 
for  a  Weak  Tendo  Achilles. — This  operation  is  identical  with  the 
operation  for  transplantation  of  the  tibialis  posticus  excepting  that  the 
long  flexor  digitorum  tendon  is  used.  It  is  readily  recognized  by 
the  surgeon;  as  he  raises  the  tendon  on  a  blunt  dissector  it  will  cause 
the  toes  to  contract. 

The  after  treatment  is  the  same  as  that  for  transplantation  of  the 
peroneii. 

164.  Operation  for  Transplantation  of  the  Tibialis  Posticus  for  a 
Weak  Tendo  Achilles. — The  tibialis  posticus  tendon  may  be  sub- 
stituted for  the  flexor  longus  digitorum  in  the  above  operation. 

165.  Transplantation  of  Peroneii  to  the  Tendo  Achilles. — Where 
the  tendo  Achilles  is  weak  or  paralyzed,  one  or  both  of  the  peroneii 
tendons  may  be  transplanted  backward  (see  figures  259  to  261), 
and  passed  through  a  slit  in  the  tendo  Achilles  and  attached  to  it  by 
quilted  silk  sutures.     The  distal  ends  of  the  peroneii  tendons,  one  or 

both  or  part  of  one  or  both,  are  attached  to  the  mal- 
leolus (see  Tendon  Fixation).  This  transplantation 
is  often  done  in  case  of  calcaneous  at  the  same  time 
that  an  astragalectomy  is  done  with  displacement  of 
the  foot  backward.     See  section  168. 

When  the  tibialis  posticus  is  paralyzed  one  of  the 
peroneii  may  be  transferred  to  it;  it  is  transplanted 
into  the  posterior  tibial  tendon  back  of  the  internal 
malleolus.  The  line  of  the  muscle  is  changed  at  the 
middle  of  the  calf.  The  transplanted  tendon  is 
quilted  with  silk  in  the  usual  way,  then  passed 
through  a  slit  in  the  tibialis  posticus  tendon  and  the 
silk  quilted  and  tied  in  this  tendon.  The  inner  half  of 
the  tendo  Achilles  and  its  muscle  may  be  used  for 
Fig.    261.  --  The  the  same  purpose  as  described  for  the  transfer  of  its 

ES    the*" Lndo    ™tCT  half  t0  the  P«0ndi- 

Achilles  and  fastened  166.  Operation  for  Paralysis  of  Extensor  of  the 
with -silk  sutures.  Great  Toe.  (Transplantation  of  its  Distal  End  to 
that  of  the  Tibialis  Anticus). — The  patient  lies  on  his  back,  the  opera- 
tor stands  on  the  side  of  the  leg  to  be  operated  on. 

An  incision  is  made  two  inches  long  through  the  skin  and  fat  over 
the  anterior  lower  third  of  the  leg.  The  skin  and  subcutaneous  fat 
are  retracted  and  the  extensor  tendons  are  exposed.  Lifting  each  tendon 
on  a  blunt  instrument  will  give  sufficient  pull  to  show  to  which  toe  it 
extends. 

The  distal  end  of  the  extensor  tendon  of  the  great  toe  is  isolated  and 
sutured  through  a  slit  made  in  the  tibialis  anticus.  The  degree  of  tension 
should  be  carefully  estimated  in  order  not  to  cause  a  hammer  toe.  The 
tension  should  be  a  little  less  than  that  of  the  tibialis  tendons.  A  plaster 
is  applied  with  the  foot  at  right  angles.    After  three  or  four  weeks  the 


MUSCLE  AND  TENDON  OPERATIONS  147 

patient  walks  on  the  foot  with  the  plaster.    After  that  it  is  gradually 
omitted  as  walking  improves. 

167.  Operation  for  Transplantation  of  the  Tibialis  Posticus  to  the 
Tendo  Achilles. — The  patient  lies  on  his  back,  with  his  leg  outwardly 
rotated,  a  sand  bag  or  heavy  pillow  may  be  placed  under  the  buttock  of 
the  opposite  side.  The  operator  stands  on  the  same  side  of  the  table 
as  the  leg  to  be  operated  on. 

OPERATION 

An  incision  is  made  parallel  to  the  tibia  extending  one  inch  above  and 
one-half  an  inch  posterior  to  the  internal  malleolus,  extending  up  to  the 
middle  and  upper  third  of  the  leg.  The  tibialis  posticus  tendon  is 
isolated  and  held  on  a  blunt  dissector.  It  may  be  distinguished  from 
the  long  flexor  of  the  toe  as  the  latter  will  contract  the  toes  when  lifted 
on  a  blunt  dissector.  An  assistant  holds  the  incision  retracted  down- 
ward by  a  hooked  retractor  and  the  tibialis  posticus  tendon  is  cut  away 
low  down,  unless  half  of  it  is  to  be  attached  to  the  internal  malleolus 
(see  Tendon  Fixation  for  Valgus) .  The  tendon  and  muscles  are  dissected 
up  to  the  middle  of  the  leg.  Two  sterile  towels  are  placed  about  the 
tibialis  posticus  muscle,  one  above  and  the  other  below.  The  tendon 
tip  is  held  by  the  hemastatic  while  the  operator  quilts  silk  up  one  side 
and  down  the  other  (see  figure  227).  The  silk  is  carefully  tested  before 
inserting  it  into  the  tendon,  a  heavy  number  sixteen  or  number  eighteen 
braided  silk  is  used.  The  incision  is  next  retracted  exposing  the  tendo 
Achilles  extending  downward  from  the  junction  of  the  middle  and  lower 
third  of  the  leg.  The  tendon  of  the  tibialis  posticus  is  placed  through  a 
slit  in  the  tendo  Achilles  and  sutured  there  by  means  of  quilted  silk 
sutures  as  shown  in  figure  261.  The  operation  is  sometimes  done  in 
connection  with  an  astragalectomy  when  there  is  paralysis  of  the  poste- 
rior muscles.  The  plaster  and  after  treatment  is  the  same  as  that  for 
transplantation  of  the  peroneii  muscles,  excepting  that  the  foot  is  put 
in  a  few  degrees  of  equinus.  A  plaster  or  wooden  heel  is  used  for  early 
locomotion  with  the  plaster  on. 


CHAPTER  III 


OPERATION  IN  CASES  OF  PARTIAL  OR  TOTAL  PARALYSIS  ABOUT  THE 

ankle.     (See  also  Chapter  II) 

168.  Astragalectomy  and  Displacement  of  the  Foot  Backward  for 
Flail,  Partially  Flail  or  Foot  Operation. — (Devised  by  Dr.  Whitman). 

operation 

The  patient  lies  on  his  back,  the  operator  stands  on  the  same  side  of 
the  table  as  the  ankle  to  be  operated  on.     One  of  two  incisions  may  be 
used;  either  an  incision  starting  posterior  to  the 
external  malleolus  and  one  inch  above  it  sweep- 


Fig.  262.— The  usual  in- 
cision for  removal  of  the 
astragalus  and  for  opera- 
tions on  the  ankle  joint. 
Circular  incision. 


Fig  263. — Anterior  external  incision  used  for  astraga- 
lectomy in  paralytic  cases  when  the  sub-periosteal 
method  of  elevating  the  tissues  is  employed. 


ing  around  anteriorly  in  a  circle  to  the  middle  of  the  tarsus  and  then 
curving  downward  to  the  base  of  the  second  or  third  metatarsal 
(see  figure  262),  or  a  vertical  incision  (see  figures  263,  264)  is  made 
two  and  one-half  inches  long  anterior  to  the  external  malleolus  and 
extending  downward  to  the  inner  side  of  the  peroneii  tendons.  In 
infantile  paralysis  where  the  object  of  the  operation  is  to  give  stability 
at  the  joint  and  to  interfere  as  little  as  possible  with  the  circulation  in  a 
patient  where  the  circulation  is  none  too  good,  the  operator  prefers  the 
second  incision  which  disturbs  the  circulation  much  less.  In  using  this 
incision  it  is  possible  to  do  the  operation  in  thirteen  minutes  including 
very  extensive  attention  to  the  tibia  and  both  malleoli.  The  incision 
in  no  way  hampers  the  operator  as  soon  as  he  understands  how  to  remove 
the  astragalus. 

The  incision  extends  down  to  the  bone,  is  made  vertically  23^  inches 

148 


OPERATION  IN  CASES  OF  PARALYSIS  ABOUT  THE  ANKLE     149 


long  anterior  to  the  external  malleolus  curving  slightly  anterior  to  the 
peroneii  tendons,  the  surgeon  using  the  scalpel.  The  posterior  edge  of 
the  incision  is  retracted  slightly  (see  figure  265).  The  operator  uses  an 
osteotome  on  the  external  malleolus  to  remove  the  attachment  of  the 


Fig.  264. — Incision  anterior  to  the 
peroneii  tendons  in  the  foot. 


Fig.  265. — Retraction  of  skin  and 
fat. 


Fig.  266. — Subperiosteal  re- 
moval of  tissues  from  the  anterior 
surface  of  external  malleolus. 


1     *   ^3 

Fig.  267.— 1,  Oscalcis.     2, 
tragalus.     3,  Cuboid. 


As- 


Fig.  268.— De- 
taching the  peri- 
osteum and  tis- 
sues from  the 
external  malleo- 
1  u  s,  subperios- 
teally. 


lateral  ligament  subperiosteally  (figures  266  to  270). 
He  removes  all  the  tissues  subperiosteally  from  the 
under  side,  the  back  and  inner  side  and  the  front 
of  the  lower  fibula  for  one  inch  or  more  (see  figure  268).  The  an- 
terior edge  of  the  incision  is  next  retracted  (see  figure  269).  The 
osteotome  lifts  the  tissues  from  the  bone  well  forward.  The  neck 
of  the  astragalus  is  cut  as  far  forward  as  possible  (figures  270,  271). 
The  bone  here  is  cut  completely  across.     The  osteotome  is  withdrawn 


150 


TECHNIQUE  OF  OPERATIONS 


and  placed  above  the  astragalus  on  its  tibial  articular  surface  as  far  in- 
ward as  possible  (figure  271).  The  foot  is  adducted  for  this  purpose.  The 
bone  is  cut  vertically  clown  and  back  leaving  a  narrow  flat  disk  close  to 
the  internal  malleolus.  There  is  now  beside  this  disk  two  other  pieces 
of  the  astragalus.  A  large  piece  close  to  the  external 
malleolus  and  a  small  knob  forward  of  the  neck  (see 
figure    271).     The   outer   portion   of   the    astragalus  is 


Fig.  269.— Show- 
ing relative  position 
of  the  tibia,  fibula 
and  astragalus. 


Fig.  270. — Astragalus. 


.,  ,         .      ...  ,      „  ,  ..  Fig.  271. — Lower  line,  os- 

easily  removed  and  will  be  found  most  adherent  teotome  cutting  the  neck  of 

On    its    Under    Surface.     The    Operator    at    this    the  astragalus,  as  far  forward 

point  may  dislocate  the  foot  inward  as  seen  ZESteStS.'tZS. 
in  figure  272,  or  he  may  remove  first  the  inner  lus,  from  above  downward,  at 
disk-like  portion  of  the  astragalus  from  its  at-  the  inner  side-  close  t0  the 
tachment  to  the  internal  malleolus.    The  lower 

end  of  the  astragalus  beyond  the  neck  is  very  easy  to  remove  as  it 
has  practically  no  attachments,  if  the  first  osteotomy  is  done  for- 
ward enough.  When  the  astragalus  has 
been  removed  completely  the  foot  is  dis- 
placed inward  exposing  both  malleoli 
(see  figure  272).  The  tissues  are  dis- 
sected subperiosteal^  with  an  osteotome 
from  the  posterior  surface  of  the  fibula; 
extending  inward,  they  are  removed 
subperiosteally  from  the  posterior  sur- 
face of  the  tibia  for  an  inch  upward 
and  from  the  posterior,  anterior,  and 
outer  surface  of  the  internal  malleolus. 
If  these  tissues  are  not  carefully  removed 
sment  of  the  the  foot  will  not  displace  backward  as  it 
should  and  an  eversion  of  the  foot  will 
be  present  which  is  undesirable  in  para- 
lytic cases,  especially  when  the  muscles 
that  lock  the  knee  are  weak  or  com- 
pletely paratyzed.  The  operator  replaces  the  foot  and  dislocates  it 
backward.   He  uses  his  finger  through  the  wound  to  see  if  any  tissues 


Fig. 

foot  inward,  after  removal  of  the  as 
tragalus  giving  full  access  to  the  tibia 
and  the  malleoli,  anteriorly  and 
posteriorly. 


OPERATION  IN  CASES  OF  PARALYSIS  ABOUT  THE  ANKLE     151 

resist  making  a  perfect  dislocation  backward.  It  should  be  remem- 
bered that  the  external  malleolus  is  further  posterior  in  the  foot  than 
the  internal.  This  relation  should  to  a  certain  degree  be  present  in 
order  that  the  foot  shall  not  be  everted.  If  the  tissues  have  not  been 
removed  subperiostially  from  the  fibula,  tibia  and 
tarsus  as  described  above,  it  will  be  necessary  to  shave 
off  the  inner  surface  of  each  malleolus  and  the  tarsus 
against  which  these  malleoli  rest.  The  deep  tissues 
are  brought  together  sealing  the  bony  cavity  com- 
pletely with  interrupted  chromic  catgut  sutures  num- 
ber 00,  the  subcutaneous  fat  with  interrupted  chromic 
catgut  sutures  number  00,  the  skin  with  continuous 
chromic  catgut  sutures  number  00.  A  small  dressing 
is  placed  over  the  wound  consisting  of  five  thicknesses 
of  gauze  one  inch  broad  and  extending  one-half  inch 
beyond  either  edge  of  the  wound.  Sterile  sheet  wad- 
ding is  put  around  the  foot  over  this.  The  leg  is 
well  padded  with  sheet  padding  and  a  plaster  of 
Paris  bandage  applied  from  the  toes  to  the  groin. 

In  cases  of  calcaneous,  the  foot  is  put  up  in  an      Fig.  273.— Astrag- 

equinilS  position.  alectomy    and     dis- 

\  .  ,  „  placement      of      the 

In  cases  without  calcaneous  deformity,  it  may  be  foot  backward   giv- 
put  up  in  an  equinus  position  for  a  short  time  and  }ns  a  fullness  at  the 
then  brought  to  a  right  angle  or  it  may  be  put  up  at  internal  malleolus- 
.  right  angles  at  the  time  of  the  operation.    When  a  tendon  transplanta- 
tion is  done  to  the  front  of  the  foot,  the  foot  is  put  up  at  right  angles. 

By  dissecting  the  tissues  up  subperiosteal^  they  reattach-  themselves 
readily  and  firmly,  yet  without  causing  a  stiff  joint.  The  ultimate  re- 
sult of  astragalectomies  with  displacement  of  the  foot  backward  is  very 
good.  The  patient  may  expect  from  one  to  two-thirds  of  the  normal 
motion,  sometimes  more,  and  absolute  lateral  stability. 

169.  After  Treatment. — By  using  the  subperiosteal  dissection, 
the  after  treatment  may  be  the  same  as  that  employed  for  a  Potts 
fracture  at  the  ankle.  The  patient  is  allowed  to  walk  with  a 
plaster  at  the  end  of  six  weeks  and  with  a  paralytic  at  the  end  of 
four  or  five  months,  all  apparatus  may  be  omitted.  In  growing  chil- 
dren it  is  important  to  broaden  the  heel  or  to  wear  apparatus  for  a 
year  to  prevent  the  foot  turning  one  way  or  the  other  as  the  bones  grow. 
The  shoes  should  be  kept  repaired  constantly. 

An  astragalectomy  and  displacement  of  the  foot  backward  may  be 
done  in  connection  with  transplantation  of  any  strong  muscles  to  take 
the  place  of  weak  ones.  The  transplantation  may  be  done  at  the  same 
time  as  the  astragalectomy;  the  bone  operation  precedes  the  transplan- 
tation. The  peroneii  are  often  used  in  this  way  to  re-enforce  the  muscle 
of  the  front  of  the  foot  or  to  re-enforce  the  muscles  on  the  back.  Other 
muscles  may  be  used  instead  of  the  peroneii  for  the  same  purpose.    These 


152 


TECHNIQUE  OF  OPERATIONS 


transplantations  arc  done  as  described  elsewhere  in  these  pages;  the 
insertion  of  the  tendons  will  be  further  forward  at  the  tarsus  on  account 
of  the  displacement  of  the  foot  backward. 

The  original  plaster  should  not  be  changed  until  the  sixth  week. 
This  assures  good  displacement  of  the  foot.  If  the  plaster  is  poorly 
applied  the  foot  will  slip  forward.  This  may  be  corrected  under  an 
anaesthetic,  never  without,  at  the  end  of  the  first  week. 

170.  Application  of  Plaster  Following  Astragalectomy. — As  the 
foot  is  being  placed  in  a  special  position  it  is  important  that  the  operator 
who  has  manipulated  the  foot  at  the  time  of  operation  should  hold  the 
foot  at  the  time  of  the  application  of  the  plaster,  in  order  to  be  sure  that 
he  is  fitting  the  foot  to  the  tibia  as  he  has  planned  it.  For  the  same 
reason  some  detail  as  to  the  method  of  application  of  the  plaster  will  not 
be  out  of  place.  The  foot  having  been  well  protected  with  well  fitting 
sheet  wadding,  especially  the  heel,  a  cuff  of  plaster  of  Paris  bandage  is 
put  on  six  or  eight  layers  on  the  lower  end  of  the  tibia  and  another  cuff 
of  about  eight  layers  of  plaster  around  the  ball  of  the  foot.  When  these 
are  hard  the  operator  places  the  foot  in  the  desired  position,  manipulates 
it  gently  to  assure  himself  that  the  position  is  the  one  he  wishes  and  that 
the  ankle  motion  is  smooth  and  free.  He  holds  the  foot  by  the  cuff  of 
plaster  with  his  right  hand  and  the  cuff  around  the  tibia  with  his  left. 
The  assistant  finishes  the  plaster  connecting  the  two  cuffs.  When  this 
third  portion  of  the  plaster  has  hardened,  the  posi- 
tion of  the  foot  is  fairly  assured.  A  well  fitting  plaster 
over  the  rest  of  the  leg  is  applied,  extending  to  the 
groin. 

171.  Operation  for  Insertion  of  Silk  Ligaments  at 
the  Ankle. — Silk  ligaments  at  the  ankle  are  useful  to 
maintain  lateral  stability  and  prevent  toe  drop  in 
adults  and  children  as  a  permanent  measure  in  para- 
lytic conditions.  They  may  be  used  in  children  for 
the  same  purpose  as  a  temporary  measure  during  the 
recovery  of  the  muscles.  They  are  useful  as  per- 
manent ligaments  to  prevent  toe  drop  and  to  increase 
the  lateral  stability  when  the  ankle  is  not  flail,  but 
weak.  This  is  especially  the  case  when  the  anterior 
muscles  are  paralyzed  and  there  is  very  little  power 
in  the  posterior  muscles.  They  are  useful  in  this 
instance  in  adults  and  in  children.  The  silk  ligament 
is  not  of  value  to  maintain  lateral  stability  when  op- 
posed to  strong  muscles,  or  for  a  flail  ankle.  In  suitable  cases  they 
will  make  braces  unnecessary  at  the  ankle  and  will  give  sufficient 
stability  here  for  weight-bearing.  In  adults  at  the  ankle  they  may 
be  applied  directly  to  the  bone  above  and  to  the  bones  of  the  foot  be- 
low (see  figure  279).  Where  they  are  to  be  used  temporarily  in  children, 
they  may  also  be  applied  to  the  bone  above  and  the  bone  below.    When, 


Fig.  274.— Perios- 
teum incised,  for  the 
insertion  of  silk  liga- 
ments. 


OPERATION  IN  CASES  OF  PARALYSIS  ABOUT  THE  ANKLE     153 


however,  they  are  used  in  children  to  remain  permanently,  the  upper  at- 
tachment should  be  made  to  the  everted  edges  of  the  periosteum  as  de- 


Fig.  275..  —  Inci- 
sions for  the  inser- 
tion of  silk  ligaments 
in  the  lower  third  of 
the  leg  and  at  the 
tarsus. 


Fig.  276.— Method 
of  elevating  the 
edges  of  the  everted 
periosteum  prepara- 
tory to  the  insertion 
of  silk  ligaments. 


Fig.  277.  —  The 
silk  quilted  up  one 
side  and  down  the 
other  of  the  everted 
periosteum ;  a  second 
strand  being  tied 
into  the  first  silk,  to 
give  four  ends.  (See 
next  figure) . 


scribed  below  (see  figure  277) ,  in  order  to 
allow  further  growth  without  relative 
contracture. 

172.  Silk  Ligament  Operation  at  the 
Ankle.  Open  Method. — The  patient  lies 
on  his  back,  the  operator  stands  to  the 
outer  side  of  the  ankle  to  be  operated  on. 

An  incision  is  made  over  the  anterior 
and  lower  third  of  the  tibia  two  inches 
long  down  to  the  periosteum  (see  fig- 
ures 274,  275).  This  is  incised,  its  edges 
everted  (see  figure  276) ,  silk  is  quilted  up 
one  side  and  down  the  other  (see  fig- 
ure 277).     The  second   piece  of   silk  is  _  F;Gn278\TuMethodJof1,t^ngihe 

'  -n    •         i  -i  •    •  first  silk  and  the  second  silk  together 

tied  to   the  Silk  m    the   periosteum  giving    to  give  four  strands.    The  first  is  in- 
f Our  Strands  (figures  278  and  279).      The    serted  into  the  periosteum.    A,  First 

point  of   insertion   in  the   foot  is  next  ^^silk"  §!"t 

Selected  with  a  View  to  gOOd  leverage  and    strand  tied.      D,  The  second  strand 

balance.    A  curved  incision  is  made  over  ^ed  giving  four  strands  for  inser- 

.,  ■    i     •     j  i       <•      ■     i  <■•  .  •  tion  m  the  periosteum  of  the  tarsus. 

the  points  in  the  toot  chosen  tor  insertion, 

one  to  the  outer  side,  the  other  to  the  inner  side  (see  figure  275).     The 

silk  is  carried  subcutaneously  from  the  leg  to  the  foot  incision  (see 


154 


TECHNIQUE  OF  OPERATIONS 


figure  280).  At  the  cuboid  and  dorsal  cuneo-cuboid  ligaments,  the 
silk  is  quilted  through  the  periosteum  as  described  for  transplanting 
the  peroneii.  On  the  inner  side  of  the  foot  a  curved  incision  is 
made  over  the  scaphoid  and  internal  cuneiform,  the  silk  is  carried 

subcutaneously   from    the   anterior 
incision  in  the  leg  to  this  incision 
and  there  inserted  by  quilted  sutures 
(figure  232).    The  knots  are  pressed 
down  and  flattened  after  three  ties. 
The  muscle  fibers  of  the  short  ex- 
tensor digitorum  are  retracted  be- 
fore   insertion    of   the   silk   in   the 
periosteum  and  become  useful  cover- 
ing for  the  knot  and  silk  at  its  inser- 
tion on  the  outer  side  of  the  foot. 
On  the  inner  side  the  tendons  may 
be  used.    The  deep  fascia  is  brought 
together  over  this 
with     interrupted 
chromic  catgut  su- 
tures number  00, 
the    subcutaneous 
tissues     with     in- 
terrupted chromic 
catgut    sutures 


Fig.  279.— Second 
strand  tied  to  the 
first,  giving  four 
strands,  two  for 
each  side  of  the 
foot. 


Fig.  280.  —  Ten- 
don carrier  used  to 
draw  the  silk  down 
to  the  tarsus. 


Fig.  281.— Perios- 
teal needle,  short, 
round,  not  brittle, 
with  a  large  eye; 
the  needle  is  flat- 
tened at  the  eye. 


number  00,  the  skin  with  continuous  chromic 
catgut  sutures  number  00. 

Before  tying  these  ligaments  each  silk 
strand  is  pulled  firmly  through  its  periosteal 
insertion  so  that  it  will  firmly  hold  the  foot  in 
very  slightly  overcorrected  position.  When 
the  tendo  Achilles  is  resistant  or  its  muscles 
are  strong,  it  is  advisable  to  stretch  the  foot 
well  upward  and  do  a  tenotomy  of  the  Achilles 
tendon  before  inserting  the  silk.  All  deform- 
ities of  the  ankle  and  all  restrictions  of  motion 
should  be  overcorrected  before  inserting  the 
silk; — when  the  deformities  are  considerable 
they  should  be  corrected  at  a  previous  opera-      FlG-    282.  —  Short    needle 

..     *        m,       P      .     *        ,  ,  ,       n      -i  i      •        li    v  holder,     forcing      the      needle 

tion.     The  foot  should  be  flexible  m  all  direc-  thr0Ugh  the  periosteum;  pres- 

tions   at    the    time   of    applying   the   artificial    sure  is  applied  on  the  needle 

liffampnts  holder  close  to  the  needle,  but 

°  '  .  .  .  .  no    twisting    force    should    be 

The  needles  used  for  periosteal  insertion  used  in  order  not  to  break  the 
are    shown    in    figure    281.     In    forcing  the  needle, 
needle  through  the  periosteum  and  superficial  part  of  the  bone,  a  heavy 
hemastatic  is  very  useful.    The  pressure  exerted  by  the  surgeon  should 


OPERATION  IN  CASES  OF  PARALYSIS  ABOUT  THE  ANKLE    155 


not  be  applied  at  the  handle  of  the  hcmastatic  but  near  the  needle  with 
the  finger  or  thumb  of  the  left  hand  on  the  hemastatic  as  shown  in 
figure  282. 

173.  Silk     Ligament     Operation. — Dr.     Bradford's     subcutaneous 
method.    Subcutaneous  silk  ligaments  may  be  applied  rapidly  with  very 


Fig.   283. 


ments. 


"-iw  m.^ 


Fig.  284.-Drill       Fig.     285. -Silk 
ing     the    tibia    and  with     silk     wormgut  wormgut  leader  used       Fig.    286.  —  Silk 
tarsus  for  silk   hga-  leader    inserted    into  to     carry     the      silk  passed     through    the 
the  end  of  the  drill.       through  the  tibia;  drill  tibia,    tendon    carrier 
inserted    through  the  from  the  outer  side  of 
tarsus.    Silk  wormgut  the  foot,  to  the  outer 
leader  passed  through  side  of  the  leg,  receiv- 
the  eye  of  the  drill.       ing  the  silk. 

little  disturbance  to  the  tissues. 
The  point  in  the  lower  third  of  the 
tibia  is  selected  (figure  283),  the 
skin  over  the  bone  is  slid  backward; 
a  drill  with  an  eye  in  its  end  is 
passed  through  the  skin  and  tibia 
(figure  284);  as  it  protrudes  from 
the  bone  on  the  other  side  of  the 
leg,  the  skin  is  slid  forward  and  the 
drill  pushed  through  it.  In  this 
;  n  way  the  hole  in  the  skin  and  in  the 

through      the     tibia  carrier  completing  the  D0n6  Will   be  Out  of   line.      The   tWO 

d°T  tt0  bthd  leg'  silk  insertion-  ends  of  a  piece  of  silk  wormgut  are 

through  the  tarsus  Passed  through  the  eyes  in  the  drill  and  withdrawn 
by  means  of  a  silk  with  it  (figure  285).  The  loop  in  the  silkworm  gut  is 
wormgut  leader.  ie^.  protruding  on  one  side  of  the  leg,  the  two  ends  at 
the  other  side.  The  exit  of  the  drill  in  the  skin  is  made  at  a  different 
level  to  the  bone  exit.  This  is  done  by  pulling  the  skin  to  one  side 
of  the  bone  before  the  drill  perforates  it  as  described  above.  The  tarsal 
bones  are  drilled  in  a  similar  way  (figures  283  and  285).  As  the  drill 
is  withdrawn  a  guide  of  double  silkworm  gut  is  pulled  through  the  bone 


156 


TECHNIQUE  OF  OPERATIONS 


so  that  the  loop  protrudes  at  one  side  of  the  foot  and  the  two  ends  pro- 
trude at  the  other  side.  A  double  strand  of  heavy  braided  silk  number 
16  or  18  is  carried  through  the  tibia  bones  by  means  of  the  silkworm 
gut  guide.  A  carrier  is  introduced  at  the  skin  puncture  at  the  side 
of  the  tibia  (see  figure  286).  This  guide  is  carried  up  subcutaneously 
and  brought  out  through  the  skin  hole  above  (figure  286).  The  silk  is 
passed  through  the  eye  of  the  carrier  and  drawn  downward  (figure  287). 
This  silk  is  next  passed  through  the  loop  of  the  silkworm  gut  and 
drawn  through  the  tarsus.  The  carrier  is  next  inserted  to  the  inner  side 
of  the  tibia  through  the  skin  and  carried  downward  subcutaneously  so 
that  it  protrudes  below  at  the  midtarsal  region.  The  silk  here  is  passed 
through  the  eye  of  the  carrier  and  drawn  upward  subcutaneously  so  that 
both  ends  of  the  silk  now  protrude  from  the  same  hole  above  (figures  288, 
289).  The  ligaments  are  drawn  tight  and  the  foot  elevated.  The  silk 
is  then  tied  and  the  ends  cut;  the  skin  is  drawn  outward  over  the  knot 
which  now  slides  through  the  tissues  and  lies  close  to  the  bone.  The 
skin  perforation  being  at  a  different  level  from  that  of  the  drill  hole  in 


Fig.  289.— Silk  just 
before  tying. 


Fig.  290.— Silk  lig- 
aments. Silk  in- 
serted from  the  tibia 

the    bone,   no    sutures  S^nSSL*0  ^ 
are  necessary.  The  foot 


vent  toe  drop. 


should  be  held  in  a  very  slight  overcorrection  by  „ ^ f  1i_Tend^1  °,f  th! 

,.,,..  .  ,.  J     peroneus    longus    displaced 

the  silk  ligament.    Plaster  is  applied  holding  the  forward,  and  sutured  in  a 
foot  so  that  no  strain  comes  on  the  silk  ligament.    eroove  in  the  bone. 

174.  Tendon  Fixation. — In  the  use  of  tendon  fixation,  advocated 
and  improved  by  Dr.  Galli,  slight  overcorrection  of  the  deformity  should 
be  made.  Either  the  whole  of  the  tendon  may  be  cut  away  above  and 
the  distal  end  put  in  a  groove  in  the  bone  to  grow  and  be  nourished  there 
by  the  bone  and  periosteum  to  which  it  becomes  attached,  or  instead  of 
using  the  whole  of  the  tendon  the  tendon  is  split  and  one-half  left  in- 
tact; the  other  half  cut  and  its  distal  end  used  for  tendon  fixation.  In 
this  way  any  tendency  of  the  muscle  to  regenerate  will  be  safeguarded. 


OPERATION  IN  CASES  OF  PARALYSIS  ABOUT  THE  ANKLE     157 


This  method  of  tendon  fixation  is  not  recommended  where  there  is 
extreme  deformity  or  where  the  tendon  fixation  would  be  opposed  to 
strong  muscles  or  for  total  flail  conditions  of  the  ankle. 

175.  Tendon  Fixation  for  Varus.  Dr.  Galli's  method.  When  the 
peroneii  are  paralyzed  and  tendon  fixation  is  decided  upon,  a  vertical 
incision  is  made  on  the  outer  aspect  of  the  lower  end  of  the  fibula.  The 
skin  is  retracted  exposing  the  fibula  three  inches  from  the  tip  of  the  bone. 
"With  a  periosteal  elevator,  the  periosteum  is 
raised  one-eighth  of  an  inch  or  more  on  either 
side  of  the  incision  and  in  the  case  of  the  epiphy- 
sis or  epiphyseal  cartilage,  the  perichondrium 
and  a  flake  of  cartilage  are  raised  with  a 
knife.  ..."  With  a  gouge  a  groove  is  made  two 
and  one-half  inches  long  and  one-eighth  of  an 
inch  wide,  to  receive  the  peroneii  tendons.  The 
tendon,  denuded  of  its  tendon  sheath,  is  placed 
in  the  groove.  The  tendon  does  not  attach  itself 
to  the  bone  but  slides  if  the  sheath  is  not  re- 
moved. The  foot  is  brought  around  in  the  posi- 
tion desired,  the  tendon  pulled  tight  and  fastened 
to  the  periosteum  by  a  silk  suture.  It  is  also 
fastened  below  by  a  silk  suture  which  prevents  it 
from  slipping;  its  upper  end  may  be  turned  down. 
The  peroneus  longus  is  displaced  forward  before 
being  placed  in  this  groove  on  the  front  of  the 
fibula  (see  figure  291).  The  peroneus  brevis  is  al- 
lowed to  remain  under  the  external  malleolus  and 
placed  in  a  groove  on  the  posterior  aspect  of  the 
fibula  (see  figure  292) .    The  periosteum  is  ele-  peroneus  longus  displaced 

vated,    a   groove   two    and    one-half    inches    long    forward  and  inserted  in  a 
,  .   ,  , ,        c  .      ,        .  ,      .  ,  i        groove  in  the  bone. 

and  an  eighth  of  an  inch  wide  is  made  on  the 

posterior  aspect  of  the  fibula  to  receive  this  tendon.  The  tendon  is 
denuded  of  its  sheath,  placed  in  the  groove,  the  periosteum  brought 
together  over  it,  the  tendon  doubled  over  at  the  top,  having  first  been 
pulled  tightly  and  sutured  at  the  upper  end  of  the  tunnel  and  at  the 
lower  end  of  the  tunnel  with  one  or  two  silk  sutures. 

176.  Tendon  Fixation  for  Valgus. — Dr.  Galli's  method.  Where 
there  is  marked  valgus  and  the  tibialis  anticus  is  completely  paralyzed, 
an  incision  is  made  on  the  anterior  and  inner  aspect  of  the  lower  end 
of  the  tibia  down  to  the  tibialis  anticus.  A  groove  is  made  in  the  lower 
end  of  the  tibia  similar  to  that  in  the  fibula  (see  figures  291  and  292), 
one-eighth  of  an  inch  wide  and  two  and  one-half  inches  long.  The 
tendon  of  the  tibialis  anticus  is  denuded  of  its  sheath,  and  drawn  into 
the  groove.  The  periosteum  is  brought  together  over  this,  the  ten- 
don is  turned  over  at  the  top  and  sutured  with  one  or  more  silk 
sutures,  at  the  upper  and  lower  ends  of  the  tunnel.    A  tunnel  should 


of 


Fig.  292. —  Tendon 
the  peroneius  brevis  in- 
serted in  a  groove  in  the 
bone      posteriorly.        The 


158 


TECHNIQUE  OF  OPERATIONS 


be  made  in  a  similar  way  for  the  tibialis  posticus  on  the  inner  side  of 
the  tibia. 

177.  Tendon  Fixation  for  Calcaneous. — Dr.  Galli's  method.  In 
cases  of  calcaneous,  an  incision  is  made  along  the  whole  length  of  the 
tendo  Achilles.  The  sheath  is  split  throughout  the  length  of  the  incision 
and  the  tendon  exposed.  It  is  freed  from  its  attachments  to  the  sheath 
and  retracted  inward  so  as  to  expose  the  fibrinous  covering  of  the  deep 
muscles  of  the  leg.  A  vertical  incision  is  made  through  this  sheath 
(which  is  the  intermuscular  septum  between  the  deep  and  superficial 
layers  of  the  flexor  muscles  of  the  leg)  and  the  long  flexor  longus  hallucis 
comes  into  view.  This  muscle  is  then  retracted  inward,  exposing  the 
posterior  surface  of  the  shaft  and  lower  extremity  of  the  tibia.  About 
three  inches  of  the  tibia  is  exposed.  A  vertical  incision  is  made  through 
the  periosteum.  A  large  gouge  is  used  to  open  up  the  medullaiy  cavity 
of  the  bone.  This  trough  receives  the  tendo  Achilles  and  the  periosteum 
is  closed  in  over  it.  If  the  leg  is  short  the  patient  is  put  up  in  slight 
equinus,  if  not  the  tendon  is  held  with  the  foot  at  right  angles.    In  some 


Fig.  293.  —  Tibia 
drilled,  silk  wormgut 
leader  placed  in  eye 
of  drill. 

cases  a  tendon  fixa- 
tion of  one-half  the 
tendon  has  been  used 
and  the  other  half  al- 
lowed to  remain  at- 
tached to  its  muscle, 
limited.  Fixation  in 
transplantation. 


Fig.  294.— Silk  worm- 
gut  leader  loop  ready  to 
draw  a  second  silk  worm- 
gut  leader  through  the 
tibia,  and  with  it  the 
rolled  end  of  the  fascia. 
The  drill  is  passed 
through  the  tarsus  and 
receives  a  silk  wormgut 
leader  here. 


Fig.  295.— The  fascia  is 
drawn  through  the  bone  by 
the  first  silk  wormgut  leader 
and  with  it  the  second  silk 
wormgut  guide  which  is  used 
to  draw  the  second  end  of 
the  fascia  through  the 
tibia. 


In  this  way  only  the  deforming  part  of  the  motion  is 
plaster  of  Paris  is  used  as  described  for  tendon 


OPERATION  IN  CASES  OF  PARALYSIS  ABOUT  THE  ANKLE     159 


178.  Fascia  Transplantation  for  Toe  Drop. — The  patient  lies  on  his 
back,  the  operator  stands  on  the  same  side  of  the  table  as  the  leg  to  be 
operated  on.  An  incision  is  made  three  inches  long  over  the  front  of  the 
lower  third  of  the  tibia  down  to  the  bone,  the  tissues  are  retracted,  the 
bone  drilled  with  a  large  drill  made  with  an  eye  in  its  end.  A  double 
strand  of  silkworm  gut  is  passed  through  the  drill  to  act  as  a  guide 
(see  Operation  for  Silk  Ligament  and  figure  293).  A  second  incision 
is  made  longitudinally  and  centrally  over  the  midtarsal  region  and  car- 
ried down  to  the  bone;  the  edges  are  retracted  and  the  bone  exposed 
with  its  overlying  periosteum. 

An  incision  is  made  five  or  six  inches  long  in  the  unparalyzed  leg  on 
the  outer  side  of  the  middle  of  the  thigh  through  the  skin  and  fat  down 
to  the  fascia  lata.  A  piece  of  fascia  may  be  removed  much  longer  and 
broader  than  the  incision  by  retracting  up,  then  down  and  then  laterally. 
The  amount  selected  should  be  estimated  by  measuring  with  a  probe. 
The  fascia  removed  should  be  not  less  than  two  inches  wider  and  two 
inches  longer  than  the  length  necessary  to  go  through  both  bone  holes 
and  cover  the  distance  between.  The  fascia  is  slit  at  each  end  (see 
figure  294),  the 
ends  are  then 
rolled.  The  roll- 
ing makes  the 
fascia  tougher, 
the  upper  ends 
are  drawn 
through  the  hole 
drilled  in  the 
tibia,  then  over- 
lapped and  su- 
tured with  inter- 
r  u  p  t  e  d  chromic 
catgut  sutures 
number  00  (see 
figure  295).  The 
fascia  is  carried 
in  a  subcutaneous 
tunnel  made  just 
below  the  fat  to 
the  lower  incision 

the    foot   (see 


m 


Fig.  296. —  Both 
upper  ends  of  the 
fascia  are  passed 
through  the  tibia 
and  sutured ;  both 
lower  ends  of  the 
fascia  are  passed 
through  the  tarsus 
ready  for  suture. 


Fig.  2  9  7. —A 
method  of  suturing 
the  fascia  with  silk 
to  the  tibia  and  to 
the  tarsus  by  quilted 
sutures. 


Fig.  298.  —  The 
fascia  sutured  to  the 
tibia  and  to  the  tar- 
sus. 


figure   296).      Or 

it   is    sutured   to 

the  periosteum  by 

quilted  silk  sutures  (see  figure  297),  or  the  bones  of  the  foot  may  be 

drilled  and  the  fascia  inserted  in  the  same  way  as  in  the  tibia. 

If  the  operator  prefers,  he  may  slit  the  periosteum  of  the  tibia  longitu- 


100 


TECHNIQUE  OF  OPERATIONS 


I 


dinally,  its  edges  then  everted  (see  figures  297  to  299),  and  the  fascia 
tucked  under  the  periosteum  and  stitched  here  with  silk  number  twelve 
or  number  fourteen.  At  the  foot  two  grooves  may  be  made  in  the  bone 
with  an  osteotome,  the  ends  of  the  fascia  tucked  each  in  his  groove  and 
the  periosteum  drawn  tightly  over  the  stitches  extending  through  the 
transplanted  fascia.  Before  attaching  the  fascia  firmly  the  foot  should 
be  brought  to  a  position  of  fifteen  or  twenty  degrees  of  dorsal  flexion 
and  be  held  here  by  the  fascia.  The  deep  tissues  are  brought  together 
with  interrupted  chromic  catgut  sutures  number  00,  the  skin  with  con- 
tinuous chromic  catgut  sutures  number  00.  A  dress- 
ing of  four  thicknesses  of  gauze,  extending  one-half 
an  inch  beyond  is  placed  over  the  wound,  then  sterile 
sheet  wadding.  A  plaster  of  Paris  bandage  is  applied 
over  this  from  the  toes  to  the  groin,  care  being  taken 
to  protect  the  heel  to  prevent  pressure  and  tension  on 
the  transplanted  fascia.  The  plaster  is  split  on  either 
side  to  allow  removal  of  the  front  half  for  inspection 
of  the  incision.  The  plaster  remains  for  eight  weeks, 
the  patient  being  allowed  to  walk  with  the  plaster  a 
little  after  the  first  six  weeks;  when  walking  becomes 
easy  a  short  caliper  with  a  double  stop  at  the  ankle 
is  used  during  the  day  and  the  plaster  at  night  to 
prevent  toe  drop  for  one  year  at  least. 

179.  Arthrodesis  for  Flail  Condition  of  the 
Ankle. — For  arthrodesis  at  the  ankle  an  incision  is 
made  starting  one-half  an  inch  posterior  to  the  ex- 
ternal malleolus  and  one  inch  above.  This  sweeps 
around  over  the  fibula  and  forward  to  the  middle  of 
the  front  of  the  foot  and  then  down  to  the  base  of  the 
second  and  third  metatarsal.  The  soft  tissues  are 
retracted  and  the  periosteum  removed  from  the  ex- 
ternal malleolus  with  its  ligaments  with  an  osteotome.  The  foot  is  dislo- 
cated outward,  a  thin  layer  of  bone  is  cut  from  the  top  of  the  tibia  and  the 
internal  aspects  of  both  malleoli  are  likewise  denuded  of  periosteum.  The 
surface  of  the  astragalus  should  fit  the  bony  surface  of  the  tibia  and  fibula, 
and  wherever  they  come  in  contact  the  bone  should  be  exposed.  The  foot 
is  replaced  and  the  bones  held  together  by  heavy  chromic  catgut  sutures 
number  1  or  kangaroo  tendon  sutures.  The  deep  tissues  are  brought 
together  with  interrupted  chromic  catgut  sutures  number  00,  the  super- 
ficial fat  with  interrupted  chromic  catgut  sutures  number  00,  the 
skin  with  continuous  chromic  catgut.  A  very  small  gauze  dressing 
is  applied  over  the  incision;  sterile  sheet  wadding  over  this.  A  plaster 
of  Paris  bandage  is  applied  from  the  toes  to  the  groin  with  the  knee 
slightly  bent,  the  foot  being  held  at  right  angles.  This  plaster  should 
be  worn  without  weight  bearing  for  about  six  weeks;  after  that  a 
light  plaster  applied  from  the  knee  downward  and  the  patient  en- 


FlG 


299. — Incisions 
closed. 


OPERATION  IN  CASES  OF  PARALYSIS  ABOUT  THE  ANKLE     161 

couraged  to  walk.     At  the  end  of  ten  weeks  he  may  walk  without 
support. 

There  are  so  many  better  operations  than  arthrodesis  at  the  ankle 
that  there  are  very  few  conditions  for  which  it  may  be  recommended. 
A  totally  flail  ankle,  known  as  "dangel  foot"  can  be  made  serviceable 
with  excellent  lateral  stability  and  yet  up  and  down  motion  by  means 
of  an  astragalectomy  and  displacement  of  the  foot  backward  which 
is  preferable  to  any  operation  which  would  stiffen  the  joint.  More- 
over, in  cases  where  the  joint  is  not  extremely  loose,  silk  ligaments  or 
ligaments  made  out  of  the  tendons  around  the  ankle  as  advocated  by 
Dr.  Galli,  are  distinctly  preferable  to  a  stiff  ankle  from  arthrodesis.  In 
walking,  arthrodesis  causes  an  awkward  motion  of  the  foot,  the  leg 
being  held  outwardly  rotated.  When  the  ankle  is  perfectly  stiff  by  an 
arthrodesis,  the  patient  walks  as  if  he  had  a  painful  flat  foot.  As  the 
front  of  the  foot  will  not  come  up,  the  toe  must  be  everted  in  order  to 
make  walking  easy. 


CHAPTER   IV 


INCISION,    PUNCTURE   AND    ARTHROTOMY 


180.  Arthrotomy. — A  knowledge  of  the  important  routes  of  ap- 
proach to  the  joints  will  facilitate  any  joint  exploration,  the  removal  of 
foreign  bodies,  the  repair  of  traumatic  conditions,  the  adjustment  of 
difficult  fractures,  the  reduction  of  old  and  difficult  dislocations,  the 
mobilization  of  joints  where  motion  is  partially  or  totally  lost,  and 
stiffening  the  joint  as  in  certain  paralytic  conditions,  to  relieving 
and  thoroughly  draining  suppurative  conditions;  a  knowledge  of  the 
important  routes  of  approach  to  the  joint  is  very  important.  For  each 
case,  the  operator  will  select  the  incision  best  suited  for  the  individual 
condition.     Each  joint  will  be  considered  separately  in  other  chapters. 

In  all  operations  on  the  joints,  the  incision  should  be  made  down  to 
the  synovial  membrane  and  made  large  enough  before  opening  the 
synovial  cavity.  All  bleeding  should  be  stopped  and  the  synovial 
membrane  carefully  opened.  The  joint  structures  should  be  tampered 
with  as  little  as  possible,  the  synovial  membrane  brought  together  care- 
fully and  the  layers  over  it  closed  in  order  not  to  disturb  the  function 
.  of  the  peri-articular  tissues.    Unnecessary  sepa- 

/  |  ration  of  the  tissue  layers  is  to  be  avoided. 

Tendons  should  be  left  in  their  sheath.  Any 
ligaments  that  must  be  cut  should  be  loosened 
periostically,  in  order  that  they  may  be  readily 
replaced.  Early  motion  should  be  the  rule, 
gentle  at  first,  and  gradually  increased.  Joint 
operations  should  never  be  hastily  considered 
and  should  be  avoided  by  anyone  not  familiar 
with  the  best  surgical  technique. 

181.  Anterior  External  Incision  (figure  300). 
— At  the  ankle  a  curved  incision  may  be  made 
starting  two  and  one-half  inches  above  the  ex- 
ternal malleolus  extending  along  the  anterior 
border  of  the  fibula,  curving  downward  and 
forward  just  above  the  peroneii  tendons  to  the 
cuboid.  The  tibia-tarsal  joint  line  is  a  little 
over  an  inch  above  the  tip  of  the  fibula. 
182.  Posterior  External  Incision  (figure  300). — An  external  incision 
may  be  made  halfway  between  the  external  malleolus  and  the  outer 
edge  of  the  tendo  Achilles,  starting  two  and  one-half  inches  above  the 
malleolus  extending  downward  parallel  to  the  fibula  and  curving  forward 
three-fourths  of  an  inch  below  the  tip  of  the  external  malleolus. 

162 


Fig.  300. 
nal    incision, 
ternal  incision 


Anterior  exter- 
Posterior    ex- 


INCISION,  PUNCTURE  AND  ARTHROTOMY 


163 


Fig.    301. — Anterior   inter- 
Posterior    in- 


183.  Anterior  Internal  Incision  (figure  301). — An  incision  may  be 
made  along  the  anterior  border  of  the  tibia  starting  two  inches  above 
the  internal  malleolus.  This  incision  is  carried  downward  and  forward 
to  the  tubercle  of  the  scaphoid.  Any  of  these 
incisions  may  be  carried  further  forward  for 
operation  on  the  tarsus. 

184.  Posterior  Internal  Incision  (figure  301) . 
— An  internal  incision  may  be  made  halfway 
between  the  tendo  Achilles  and  the  internal 
malleolus  starting  two  inches  above  it  and  ex- 
tending downward  and  curving  forward  one 
inch  below  the  internal  malleolus.  These  in- 
cisions will  give  access  to  the  os-calcis  and  the 
posterior  part  of  the  ankle  joint.  An  incision 
close  to  the  peroneii  or  posterior  tibial  tendons 
and  very  close  to  the  bone  at  the  malleolus  is 
very  undesirable  as  the  scar  often  becomes  ad- 
herent to  the  bone  which  gives  discomfort  and 
pain  later  on.  The  two  posterior  incisions  may 
be  joined  by  an  incision  continued  around  over  nai  incision 
the  os-calcis  and  extending  from  three-fourths  of  ternal  "Vision. 

an  inch  below  the  external  to  three-fourths  of  an  inch  below  the  internal 
malleolus.  This  may  be  done  without  carrying  the  lateral  incisions  up- 
ward or  in  addition  to  the  lateral  incisions  extended  upward.  In  view 
of  the  fact  that  the  two  posterior  incisions  above  described  give  ready 
-.  access  when  used  together  to  the  os-calcis  in  cases  of 

\  fracture  or  of  extensive  disease,  it  is  better  not  to 

use  the  horizontal  incision  over  the  os-calcis  as  the 
scar  is  often  painful  later  on  and  it  rubs  against  the 
shoe.  For  fractures  these  incisions  give  ready  access 
to  any  part  of  the  tissues.  For  disease  of  the  os- 
calcis  they  should  be  combined;  the  two  posterior 
are  sufficient  unless  the  disease  extends  far  forward 
and  involves  the  astragalus.  In  this  instance  an  an- 
terior median  incision  with  the  two  posterior  will 
give  all  the  room  that  is  necessary  for  removal  of 
bone  or  sequestra  and  for  good  drainage. 

185.  Anterior  Median  Incision  (see  figure  302)  .— 
An  interior  median  incision  is  made  two  inches  above 
the  joint  line  and  extends  vertically  downward  over 
the  midtarsus  just  external  to  the  extensor  of  the 
great  toe  to  the  base  of  the  third  metatarsal.  It  may 
be  made  over  the  middle  or  outer  third  of  the  foot. 
Plantar  incisions  should  be  avoided;  the  incision  to  the  sole  should  be 
at  one  or  both  sides  of  the  foot;  there  are  of  course  exceptional  cases 
of  foreign  bodies. 


Fig.   302.  —  Anterior 
median   incision. 


104  TECHNIQUE  OF  OPERATIONS 

186.  Circular  Incision  for  the  Exposure  of  the  Ankle  Joint.  (See 
Figs.  303  and  30-4.) — An  incision  is  made  one  inch  above  the  external 
malleolus  starting  halfway  between  the  fibula  and  the  tendo  Achilles 
and  extending  forward  and  slightly  downward  to  the  front  and  middle 
of  the  tarsus,  then  curving  directly  downward  to  the  base  or  middle  of 
the  third  metatarsal. 

The  tissues  may  be  lifted  subperiosteally,  the  tendons  retracted  in 
the  tissues,  allowing  the  edges  of  the  incision  to  be  raised  for  an  inch 


Fig.  303. — Incision  for  removal 
of  the  astragalus  or  for  a  com- 
plete inspection  of  the  ankle  joint 
by  displacing  the  foot  outward. 
(See  figure  304.) 

either  way,  the  ligaments  about  the  ex-      FlG  304.— Displacement  of  the  foot 

temal    malleolus    are    Separated   Off    the    outward  after  incision  for  inspection 

anterior  internal  and  posterior  as  well  of  the  ankle-    <See  &^Te  303>- 

as  the  external  surface  of  the  fibula,  allowing  the  foot  to  be  dislocated 

inward  as  shown  in  figure  304. 

This  gives  an  excellent  view  of  the  tibio  tarsal  joint,  the  astragalus  and 
the  upper  portion  of  the  tarsus.  It  is  usually  not  necessary  to  cut  the 
tendons  to  dislocate  the  foot.  The  foot  should  be  carefully  replaced  and 
the  deep  tissues  as  well  as  the  skin  sutured.  The  external  ligaments  if 
detached  subperiosteally  from  the  fibula  will  reunite  without  suture. 
It  will  be  remembered  that  they  are  lifted  from  the  outer  side  of  the 
malleolus  with  the  skin  and  fat  and  periosteum.  After  operation  the 
foot  is  held  in  plaster  dorsally  flexed  thirty  degrees. 

187.  Arthrotomy  for  Fractures  About  the  Joints. — The  necessity 
of  immediate  operation  in  fractures  about  the  joints  depends,  as  in  other 
fractures,  on  the  acuteness  of  the  local  and  general  reaction.  When 
these  do  not  contra  indicate  immediate  operation,  certain  fractures 
about  the  joints  may  require  treatment  by  the  open  method.  Among 
these  are  fractures  of  the  patella,  fractures  of  the  olecranon  and  certain 
fractures  of  the  surgical  neck  of  the  humerus  and  certain  fractures  of 
the  neck  of  the  femur,  all  compound  fractures,  even  when  the  protrusion 
of  the  bone  has  been  extremely  slight,  all  fractures  that  cannot  be  re- 
duced by  manipulation  or  in  which  the  correction  cannot  be  main- 
tained or  where  apposition  is  impossible,  many  fractures  combined  with 
dislocation,  articular  fractures  with  pieces  locking  or  limiting  the  joint 
action. 


INCISION,  PUNCTURE  AND  ARTHROTOMY  165 

Where  there  is  a  great  deal  of  trauma  and  in  multiple  fractures  and  in 
cases  where  there  is  a  great  deal  of  shock,  all  that  can  be  done  is  to  im- 
mobilize the  parts  until  a  favorable  time  for  operation.  In  selecting  a 
suitable  time  for  operation,  when  it  is  found  necessary  to  operate  on  a 
fracture  if  there  is  no  immediate  contra  indication,  the  sooner  it  is  done 
the  better.  Where  there  is  extreme  swelling  the  surgeon  should  always 
wait.  All  cases  should  be  operated  on  that  show  no  union  after  three 
months  of  good  treatment. 

Methods  of  treating  the  individual  fracture  cannot  be  considered  in  a 
limited  space  like  this.  The  writer  has  described  the  routes  of  approach 
to  the  different  joints  and  the  technique  of  these.  This  will  enable  the 
surgeon  from  his  knowledge  of  fractures  to  select  the  route  best  adapted 
for  the  individual  treatment  required  and  when  necessary  two  or  more 
incisions  may  be  used.  A  knowledge  of  the  technique  will  enable  the 
surgeon  to  work  rapidly  in  reaching  the  fracture  on  which  he  expects 
to  spend  time. 

188. — The  bones  of  the  leg  are  readily  reached  and  cut  with  an  osteo- 
tome in  the  case  of  deformity  from  fractures.  The  fresh  fractures  that 
require  open  operation  are  also  readily  reached.  It  is  important  in  frac- 
tures about  the  ankle  to  note  the  position  of  the  foot  with  reference  to 
the  patella  and  anterior  spine.  The  great  toe  should  be  in  a  line  with 
the  inner  border  of  the  patella  and  the  anterior  superior  spine.  The 
bone  should  be  otherwise  aligned  and  the  foot  not  allowed  to  drop  back. 
If  this  takes  place  the  patient  loses  the  dorsal  motion  of  the  foot,  so 
important  for  any  form  of  activity.  Anterior  bowing  at  the  point  of 
fracture  is  apt  to  take  place  and  evertion  of  the  foot.  These  must  be 
prevented  especially  in  low  fractures  of  both  bones.  If  the  malleoli  are 
fractured,  the  foot  will  displace  backward.  To  prevent  this,  the  foot 
should  be  dorsally  flexed  as  described  by  Cotton.  In  almost  all  ankle 
fractures,  the  foot  should  be  dorsally  flexed  from  twenty  to  forty-five 
degrees,  depending  on  the  case.  In  bowing  and  deformity  from  old 
fractures  after  cutting  the  bone,  a  tenotomy  of  the  tendo  Achilles  is 
usually  necesssary  to  allow  free  overcorrection  of  the  fracture. 

189.  A  Method  of  Treating  Overlapping  Fractures. — Where  the 
bones  overlap,  an  excellent  method  of  treatment  is  one  suggested  to  the 
writer  many  years  ago  by  Dr.  Edward  Martin  of  Philadelphia.  In  the 
operation  when  the  surgeon  has  reached  the  fracture  the  ends  are  freed. 
A  tough  tape  or  webbing  is  used  ten  or  twelve  feet  long,  sterilized.  The 
two  ends  of  the  tape  are  tied  together,  a  loop  of  the  tape  is  placed  over 
the  distal  end  of  the  bone.  The  other  end  of  the  tape  is  thrown  over 
the  foot  of  the  operating  table,  a  thirty-five  pound  weight  is  attached 
to  this  by  an  assistant.  In  about  five  minutes  the  bones  will  be  found 
to  be  separated  at  least  one  inch.  The  weight  is  then  held  up  by  aynon- 
sterile  assistant,  the  tape  taken  off  of  the  end  of  the  bone  and  clamped 
to  the  sheet  on  the  operating  table,  so  that  it  will  not  slip  away  while 
the  surgeon  works  on  the  fracture.     When  the  muscles  are  in  fairly 


166  TECHNIQUE  OF  OPERATIONS 

good  tone  or  the  overlapping  of  bone  has  been  great,  it  will  be  found 
that  the  bones  will  overlap  again  in  four  or  five  minutes.  A  reappliea- 
tion  of  the  tape  will  separate  the  bones  again  for  the  same  length  of 
time.  The  end  of  the  lower  bone  should  not  be  cut  or  freshened  until 
all  other  procedures  are  done  which  require  separation  of  the  bones. 
When  these  have  all  been  done  the  end  of  the  bone  over  which  the  tape 
has  been  placed  is  freshened.  After  this  the  tape  should  not  be  placed 
on  the  end  of  the  bone,  unless  it  is  very  necessary,  but  the  two  ends  al- 
lowed .to  come  together  and  held  by  a  clamp  until  the  operation  is  com- 
plete. 

Very  bad  overlapping  fractures  have  been  treated  in  this  way  in 
fresh  cases  without  the  necessity  of  shortening  the  bone.  In  old  frac- 
tures no  more  bone  need  be  removed  than  is  required  by  the  conical 
condition  of  the  ends  of  the  bone. 

190.  Fractures  of  Long  Standing  Still  Ununited  or  United  with 
Deformity,  Preventing  Function. — In  fractures  of  long  standing  where 
there  is  a  mild  infection,  conservative  treatment  should  be  tried 
first.  When  this  has  been  tried  free  drainage  should  be  established  and 
at  the  same  time  the  ends  of  the  bone  freshened  up  slightly.  Unless 
the  infection  is  marked,  in  many  of  these  cases  when  the  suppuration 
disappears,  union  has  also  taken  place.  In  any  case  where  there  has  been 
infection,  no  plastic  operation  should  be  used  until  the  infection  has  been 
entirely  absent  for  at  least  nine  months — a  year  is  safer.  Where  the  infec- 
tion is  very  mild  and  of  long  standing,  during  the  process  of  treatment  the 
patient  may  be  allowed  to  walk  on  the  other  leg  if  the  local  reaction  is 
not  too  great.  Sometimes  he  may  walk  a  little  on  the  affected  leg. 
It  is  of  advantage  in  certain  cases  to  use  a  Thomas  splint  to  take  some 
of  the  weight  off  of  the  affected  leg,  the  patient  being  allowed  to  bear 
weight  on  the  ball  of  the  foot,  the  splint  taking  all  the  weight  off  of  the 
heel.  Where  the  x-ray  shows  conical  ends  of  the  bone  it  is  practically 
useless  to  expect  union  without  surgical  interference. 

191.  Tapping  the  Ankle. — The  most  scrupulous  aseptic  precautions 
are  necessary  both  as  to  the  preparation  and  the  protection  of  the  field 
of  operation. 

When  there  is  effusion  the  joint  is  readily  reached  with  a  trocar 
either  anterior  to  the  external  or  internal  malleolus  and  just  posterior 
to  the  tendon  sheaths.  The  skin  is  drawn  to  the  side  so  that  the  hole 
in  the  skin  and  muscle  will  be  out  of  line  when  the  needle  is  removed. 
If  fluid  is  to  be  drawn,  and  other  solutions  are  to  replace  it,  the  amounts 
should  be  carefully  measured.  Two  good  graduated  metal  syringes  are 
very  useful.  All  of  their  parts  should  be  tested  beforehand.  The 
trocar  is  made  to  enter  the  joint  and  then  is  connected  with  the  syringe. 
As  little  air  as  possible  should  enter  the  joint.  The  trocar  should  be  of 
large  diameter  as  the  fluid  may  be  thick  or  flaky.  When  the  patient  is 
not  anaesthetized  for  the  operation  it  is  often  well  to  have  a  short  flex- 
ible tube  connect  the  trocar  with  the  syringe.     This  should  be  fastened 


INCISION,  PUNCTURE  AND  ARTHROTOMY  167 

at  both  ends  by  silk  ties  so  that  it  will  not  leak  easily  when  pressure  or 

■  suction  is  used.     If  the  joint  is  to  be  washed  out  a  definite  amount  of 

fluid  is  injected  and  the  return  measured  in  a  sterilized  measuring  glass. 

The  tibio-tarsal  joint  is  about  one  and  one-fourth  inches  above  the 
external  malleolus. 

Dr.  Murphy  uses  a  formalin  glycerine  solution  as  follows : — 

Liquor  formaldehyde,  2%  in  glycerine. 

About  ten  drops  of  formaldehyde  to  each  ounce  of  glycerine. 

This  acts  very  well  in  infectious  synovitis. 

But  it  should  not  be  used  in  arthritis  deformans  nor  in  old  chronic 
arthritis. 

The  solution  should  be  prepared  twenty-four  hours  before  it  is 
used  (Murphy).  The  tapping  may  be  done  with  ethyl  chlorid  or 
novocaine  adreneline  solution,  1%. 


CHAPTER  V 

OPERATIVE    TREATMENT   IN   CASES   OF   JOINT  ANKYLOSIS 

192.  Arthroplasty  for  Ankylosis. — Ankylosis  may  be  bony,  car- 
tilaginous or  fibrinous,  it  may  be  periarticular,  ligamentous  and  cap- 
sular, or  extra  articular,  that  is,  skin  scars,  tendons,  fascia,  nerves  and 
arteries. 

The  form  of  ankylosis  that  exists  will  determine  the  treatment.  A 
partial  ankylosis  at  certain  points  had  better  not  be  treated  by  an  ar- 
throplasty. 

Age  must  be  considered,  also  the  general  condition  of  the  patient. 
When  the  ankylosis  is  bony,  cartilaginous  or  fibrinous,  arthroplasty  is 
indicated.  When  the  condition  is  periarticular  or  extra  articular,  it 
may  be  treated  by  capsulotomy,  tendon  elongation,  excision  of  exostoses, 
etc. 

Dr.  Murphy  lays  stress  on  the  following  points: — The  principles  of 
asepsis  to  the  finest  detail  are  absolutely  essential.  One  not  familiar 
with  the  best  surgical  technique  should  avoid  arthroplasty  operations. 
The  exposure  of  the  joint  must  be  generous  and  careful.  The  excision 
of  the  ankylosis  must  be  complete.  The  contracted  capsular  ligaments 
and  soft  parts  must  be  freed  and  if  necessary  lengthened.  The  normal 
contour  of  the  joint  should  be  restored  as  near  as  possible.  The  operator 
should  obtain  a  hyper-mobilization  of  the  joint.  The  joint  should  be 
re-shaped  to  give  stability.  The  inter-position  of  material  to  prevent 
reunion  of  the  bone  is  necessary.  The  principle  is  to  separate  the  bones 
and  to  interpose  between  them  material  to  prevent  ankylosis.  The  best 
material  for  this  purpose  is  the  human  pedicle,  composed  of  fat,  muscle, 
fascia,  or  a  combination  of  these. 

When  this  is  not  possible,  a  transplantation  is  made  of  fat  and  fascia 
from  the  trochanter  bursa  region  or  from  the  fascia  lata. 

Material  such  as  ivory,  celluloid,  silver  are  not  good.  Materials  that 
will  not  absorb  or  that  absorb  too  slowly  are  not  desirable. 

During  the  operation  the  soft  parts  should  be  freely  liberated.  Attach 
the  interposing  flap  to  one  bone  only  and  cover  it  completely.  Early 
motion,  that  is,  at  the  end  of  five  to  seven  days  is  necessary  with  or 
without  gas  or  gas  oxygen. 

Dr.  Murphy  records  failures  in  arthroplasty  as  due  to  first,  insufficient 
and  defective  exsection  of  the  capsule  and  ligaments,  second,  insufficient 
interposition  of  fat  and  fascia  between  the  separated  bony  surfaces, 
third,  infection,  fourth,  the  sensitiveness  of  pain  on  motion  after  opera- 
tion. 

Cases  of  primary  tuberculosis  and  cases  of  recent  infection  that  have 

168 


OPERATIVE  TREATMENT  IN  JOINT  ANKYLOSIS  169 

subsided  are  not  suitable  cases  for  arthroplasty.  In  operation,  in  addi- 
tion to  the  usual  protection  of  the  field  of  operation,  after  the  skin  and 
fat  have  been  incised,  towels  should  be  clamped  to  the  edges  of  the  skin 
as  an  extra  protection. 

193.  Tibia-Tarsal  Arthroplasty. — An  incision  is  made  one  inch  above 
the  external  malleolus  starting  halfway  between  the  fibula  and  the 
tendo  Achilles  extending  forward  and  slightly  downward  to  the  front 
and  middle  of  the  tarsus,  then  curving  directly  downward  to  the  base 
or  middle  of  the  third  metatarsal. 

The  tissues  may  be  lifted  subperiosteal^,  allowing  the  edges  of  the 
incision  to  be  raised  an  inch  either  way.  The  tendons  are  retracted 
with  the  tissues.  The  ligaments  about  the  external  malleolus  are 
separated  off  the  anterior  internal  and  posterior  as  well  as  the  external 
surface  of  the  fibula,  the  joint  line  is  made  with  a  chisel  or  osteotome 
allowing  the  foot  to  be  dislocated  inward  as  shown  in  figure  304,  the 
periosteum  is  peeled  back  from  the  tibia  for  one  inch  anteriorly  and 
posteriorly.  A  piece  of  fascia  three  by  five  inches  or  larger  is  removed 
from  the  outer  surface  of  the  fascia  lata.  This  is  placed  over  the  front, 
the  under  side  and  the  posterior  surface  of  the  tibia.  When  the  fascia 
is  sutured  in  place  the  foot  is  replaced.  The  deep  tissues  as  well  as  the 
skin  and  fat  are  brought  together  with  sutures.  As  the  periosteum  was 
raised  from  the  external  malleolus,  one  inch  above  its  tip  and  stripped 
downward  with  the  external  lateral  ligament,  the  latter  will  unite 
without  suture.  A  carefully  applied  plaster  of  Paris  bandage  is  used 
holding  the  foot  dorsally  flexed  thirty  degrees. 


CHAPTER   VI 

OPERATIONS   IN   SUPPURATIVE    CONDITIONS 

194.  Suppurative  Joint  Conditions  about  the  Ankle.  (See  Carrell- 
Dakin  technique,  section  323.) — In  suppurative  conditions  about  the 
ankle  joint,  openings  and  counter  openings  should  be  used  in  severe 
cases;  in  milder  conditions  a  single  incision  is  rarely  sufficient.  One  of 
the  lateral  incisions  should  be  used  as  indicated  by  the  swelling.  When 
the  focus  is  located  another  incision  is  made  on  the  opposite  side  of  the 
joint  or  anteriorly  or  both,  as  the  case  requires. 

195.  Disease  of  the  Os-calcis  and  Tarsal  Bones. — In  disease  of  the 
os-calcis  and  tarsal  bones  when  the  condition  is  acute,  drainage  with 
opening  of  the  bone  is  indicated.  When  the  focus  is  located,  the  foot 
should  be  drained  on  both  sides  and  if  necessary  anteriorly.  If  the 
disease  is  sub-acute  and  of  long  standing  and  has  not  yielded  to  conserv- 
ative methods  or  to  through  drainage,  the  focus  as  indicated  by  an 
x-ray  should  be  chiselled  out  by  cutting  in  the  good  bone  around  the 
focus  and  removing  the  whole  disease.  Drainage  is  established  on  both 
sides  and  anteriorly  in  some  cases,  if  necessary.  The  cavities  are  irri- 
gated with  salt  solution  and  wiped  out  with  gauze  strips.  The  soft 
tissues  are  gaped  with  gauze  in  the  corners  to  keep  them  wide,  tubes 
are  placed  extending  to  the  cavities. 

The  foot  is  held  in  a  plaster  with  plaster  ropes  to  allow  large  windows 
for  dressing  (figures  451  to  456).  The  method  of  application  should  be 
carefully  planned  to  give  immobilization  without  having  the  plaster 
heavy.  The  wicks  and  tubes  are  shortened  after  the  tenth  day,  then 
removed.  By  this  method  no  further  wicks  need  be  applied  as  the 
wounds  made  large  in  the  first  place  become  round  in  shape  and  close 
slowly. 

The  whole  of  the  os-calcis  or  any  other  bones  of  the  tarsus  may  be 
removed  leaving  the  periosteum  and  a  small  shell  of  bone.  The  whole 
will  reform  in  about  six  months,  allowing  some  weight-bearing  with  the 
plaster.  When  weight-bearing  is  painless,  the  plaster  is  gradually 
omitted.  A  small  sinus  may  last  for  six  months  more,  sometimes  it 
will  close  in  three  months.  The  foul  original  condition  and  the  pain 
will  be  eliminated  by  the  operation  and  a  good  foot  for  function  will  re- 
sult ultimately. 

196.  Operations  on  the  Metatarsal  and  Phalangeal  Bones  and 
Joints.  (See  Fig.  305.) — To  reach  the  joints  or  small  bones  of  the  foot 
a  dorsal  incision  or  two  dorsal  incisions  may  be  made  between  the  line 
of  the  artery  and  the  line  of  the  tendon.  The  skin  incision  should  be 
made  down  to  the  bone  without  separating  the  fat  and  other  tissues. 

170 


OPERATIONS  IN  SUPPURATIVE  CONDITIONS  171 

In  other  words,  the  periosteum  is  raised  from  the  bone  without  expos- 
ing the  structures  between  it  and  the  skin.  This  raising  of  the  peri- 
osteum is  made  with  a  long  handled,  very  small  osteotome,  the  osteo- 
tome being  used  as  soon  as  the  knife  has  reached  the  bone.  When  the 
periosteum  is  raised,  small  dull  hooks  or  re- 
tractors are  then  used  to  hold  the  tissues  and 
expose  the  bone  or  joint.  In  a  similar  man- 
ner the  metatarsals  are  exposed. 

197.  Operation  in  Tuberculosis  of  the 
Tarsus. — An  esmark  rubber  bandage  is  ap- 
plied to  the  foot  and  leg  up  to  the  middle  of  the 
calf  and  a  tourniquet  is  applied  above  this. 

In  tuberculosis  of  the  os-calcis,  a  posterior 
lateral  incision  is  made  on  either  side  of  the 
os-calcis  one-half  inch  posterior  to  each  mal- 
leolus extending  down  and  curving  forward. 
The  incision  is  carried  down  to  the  bone;  the 
tissues  are  dissected  up  subperiosteally.  The 
incisions  are  retracted  well,  exposing  the  bone. 
The  diseased  bone  will  come  into  view,  a  chisel  fig.  305.  —  incisions  for 
is  used  in  the  healthy  bone  around  it,  chiselling  reaching  the  bones  and  joints 
away  a  small  portion  of  the  healthy  bone  "Lt^eTiods™  *""* 
around    the    focus.      The    bone    is    chiselled 

away  and  the  diseased  bone  can  be  removed  readily.  When  all  the 
disease  has  been  removed  in  this  way  by  cutting  through  the  healthy 
bone,,  the  cavity  is  wiped  out  with  strips  of  gauze  until  they  come 
out  perfectly  clean.  It  is  then  irrigated  with  salt  solution,  then  wiped 
out  again  with  long  strips  of  gauze.  As  a  rule  it  is  better  not  to  use  a» 
curette  in  bone  disease.  The  edges  of  the  wound  are  gaped  by  rolled 
gauze  sponges.  The  foot  is  held  in  slight  dorsal  flexion  by  means  of  a 
plaster  of  Paris  bandage,  extending  from  the  toes  to  the  knee.  In  "ex- 
tensive cases,  a  plaster  should  extend  to  the  groin.  The  plaster  is 
applied  with  plaster  ropes  (see  figures  451  to  456)  so  that  the  dressing 
may  be  done  without  soiling  the  plaster  or  interfering  with  the  position 
of  the  foot.  At  the  end  of  six  weeks  the  plaster  is  changed,  and  a  great 
deal  of  new  bone  will  have  formed. 

In  ten  weeks  there  will  be  almost  no  discharge.  A  small  sinus  may 
persist  for  six  months  or  longer.  The  pain  and  foul  condition  of  the 
wound  will  disappear  usually  ten  to  fourteen  days  after  the  operation. 
The  patient  is  up  in  three  weeks  and  may  walk  on  the  foot  with  the 
plaster  and  crutches  after  twelve  weeks. 

OPERATION  IN  TUBERCULOSIS  OF  THE  BONE 

In  tuberculosis  of  the  bone  in  the  foot  and  hand  with  or  without 
abscess,  operation  on  the  diseased  bone  is  to  be  avoided.  When 
conservative    methods    have   failed    complete    drainage    and    counter 


172  TECHNIQUE  OF  OPERATIONS 

drainage  is  indicated  with  an  opening  made  in  the  bone.  But 
large  abscesses  will  often  absorb  and  give  less  constitutional  symp- 
toms when  allowed  to  absorb  than  when  the  infection  becomes 
mixed  following  operative  procedures.  When  it  is  necessary  to  open 
these  abscesses .  because  they  are  about  to  break  or  because  of  the 
condition  of  the  patient  they  should  have  drainage  and  counter 
drainage,  the  cavities  wiped  out  and  washed  out  and  again  wiped 
out.  After  this  tubes  are  placed  to  all  dependent  parts  of  the  abscess 
cavity  and  gauze  used  to  gap  the  angles  of  the  incision.  These 
tubes  and  gauze  wicks  are  left  in  place  ten  days  and  then  gradually 
shortened,  no  injection  should  be  used,  nor  any  irrigation  after  opera- 
tion. The  reapplication  of  wicks  will  probably  be  unnecessary  if  the 
incisions  are  large  enough. 

In  tuberculosis  of  the  bone  it  is  rarely  necessary  to  do  more  than 
drain  and  counter  drain  the  abscesses,  sometimes  drain  the  bone 
cavity. 

It  is  better  not  to  attempt  to  excise  the  disease  excepting  in  extremely 
severe  cases.  The  small  focus  will  do  better  without  being  excised, 
the  large  ones  may  come  to  extensive  operation  and  excision.  See  sec- 
tion 212. 

In  draining  a  psoas  abscess  it  is  better  in  every  case  to  drain  the  lumbar 
region  as  well  as  the  abdomen  or  the  groin.  When  the  abdomen  or 
groin  is  opened  at  the  point  of  swelling,  a  large  urethral  sound  is  care- 
fully opened  here  and  made  to  protrude  behind,  the  operator  cuts  down 
on  the  sound  behind,  giving  posterior  drainage. 

The  rule  for  a  posterior  counter  opening  in  a  psoas  abscess  should 
always  be  followed;  the  duration  is  shorter  and  the  drainage  more 
satisfactory. 

198.  Osteomyelitis. — In  osteomyelitis  an  operation  should  be  done 
as  early  as  possible  after  making  the  diagnosis.  In  sub-acute  cases, 
incision  and  drainage  are  all  that  is  necessary.  Whenever  incising  for 
abscess  all  the  pockets  should  be  opened  and  if  the  abscess  is  large, 
counter  incisions  are  made  at  dependent  portions.  The  pus  pocket 
should  be  opened  freely,  wiped  out  with  gauze,  irrigated  and  wiped  out 
again  with  gauze.  Curetting  should  be  avoided  excepting  for  the  re- 
moval of  sinuses  in  the  skin  and  in  cases  of  sinuses  it  is  often  better 
to  excise  them.  Perforated  rubber  tubing  should  be  placed  to  drain 
the  deepest  portions  of  the  pockets.  The  skin,  fat  and  superficial 
muscle  layers  should  be  made  to  gap  by  means  of  gauze  drains. 
At  the  end  of  ten  days  the  gauze  is  removed  and  the  tubes  shortened. 
The  tubes  are  gradually  drawn  out  a  little  each  day  or  two  until 
not  used.  This  method  makes  the  repeated  reapplication  of  drains 
and  wicks  unnecessary  as  the  wound  will  gap  of  itself  and  close 
from  the  bottom  if  the  surgeon  has  been  careful  to  make  large 
incisions. 

Where  the  periosteum  is  found  destroyed  or  the  pus  under  the  perios- 


OPERATIONS  IN  SUPPURATIVE  CONDITIONS  173 

teal  layer,  the  bone  should  be  opened  by  means  of  a  large  drill  or  a  small 
gouge.  Where  this  is  necessary,  the  incisions  should  be  large  and  the 
counter  incision  should  be  made  on  the  other  side  of  the  bone  with  a 
hole  made  in  the  bone  a  little  above  or  a  little  below  the  hole  on  the 
opposite  side  (figure  66).  These  holes  in  the  bone  should  open  up  the 
medullary  cavity.  They  should  alternate  on  one  side  and  the  other  as 
far  up  and  down  as  the  disease  is  suspected.  When  the  abscess  is  very 
great  and  the  bone  involvement  is  large  a  number  of  good  sized  holes 
should  be  made  with  a  Burr  drill  or  a  curved  gouge  on  both  sides  of  the 
bone  as  shown  in  figure  67.  The  wound  should  be  gaped  widely; — 
the  skin,  fat  and  superficial  muscle  held  open  by  large  gauze  drains. 
The  tubes  should  reach  from  the  surface  to  the  deepest  portions 
of  the  abscess  cavity.  Splints  should  always  be  applied  to  immob- 
ilize the  limb.  They  should  be  placed  so  that  they  will  not  inter- 
fere with  the  dressing.  In  some  instances  it  is  better  to  apply  plaster 
with  large  windows  and  ropes  to  give  stability  as  shown  in  figures  451 
to  456.  The  dressing  should  be  done  every  day  or  twice  a  day,  de- 
pending on  the  foul  condition  of  the  discharge.  If  the  odor  is  excessive, 
chlorinated  soda  dressing  should  be  used  diluted,  using  it  1/2,  ljz  or  lji 
the  U.  S.  P.  strength.  The  gauze  drains  should  be  left  for  at  least  ten 
days  without  being  disturbed.  When  removed  granulations  will  be 
formed  under  them  in  such  a  way  as  to  keep  the  wound  open  without 
applying  the  drains.  Irrigation  may  be  used  at  the  time  of  operation 
and  the  wound  thoroughly  wiped  out  with  gauze  afterward.  No  irriga- 
tion or  probing  or  application  of  wicks  will  be  necessary  if  the  first 
drains  are  left  in  long  enough.  After  the  first  ten  days  the  tubes  are 
shortened  up  gradually  until  they  are  not  needed. 

In  severe  cases  where  the  patient  is  unconscious  or  delirious,  the  bone 
should  always  be  opened,  three  or  four  holes  on  either  side  made  with  a 
good  sized  Burr  drill  or  a  gauge.  In  no  case  should  the  incision  be  made 
only  on  one  side  of  the  leg  in  severe  cases.  No  tight  packing  should 
be  used  as  this  interferes  with  good  drainage.  Where  sequestra  have 
formed  they  should  be  removed.  An  x-ray  should  be  taken  whenever 
possible  to  determine  the  position  of  the  disease,  (unless  the  case  is  ur- 
gent and  an  immediate  x-ray  is  not  obtainable). 

In  cases  of  long  standing  that  are  sub-acute  at  the  first  examination, 
where  the  bone  is  riddled  with  holes  over  an  extremely  long  area,  it  is 
impossible  often  to  remove  the  dead  bone  satisfactorily  without  remov- 
ing all  the  bone.  In  these  cases  free  incision  down  to  the  bone  with 
frequent  openings  into  the  bone  as  described  above,  will  allow  the  septic 
process  to  run  its  course  and  the  sequestra  to  gradually  separate.  We 
have  had  some  cases  in  which  the  lower  third  of  both  femora  were 
riddled  with  holes  and  full  of  sequestra,  the  patient  being  in  no  condition 
for  extensive  operation,  and  yet  not  very  ill.  In  these  cases,  however, 
if  the  surgeon  has  seen  the  patient  in  time  an  early  operation  would 
have  prevented  this  extreme  condition. 


174  TECHNIQUE  OF  OPERATIONS 

199.  The  Carrell-Dakin  Method  of  Treating  Pus  Cavities —Much 
may  be  expected  from  this  method  in  the  future  treatment  of  suppurative 
conditions.    See  section  323. 

Sometimes  it  is  necessary  to  close  a  large  bone  cavity  which  will  not 
heal  over.  "Where  the  process  is  distinctly  septic  no  plastic  operation 
should  be  done  without  first  doing  an  operation  to  eliminate  the  infectious 
condition.  -  After  that  part  of  the  muscle  may  often  be  transferred  over 
such  a  cavity  after  it  is  closed.  In  transferring  a  muscle  over  such  a 
cavity  it  should  be  freely  transplanted  and  held  there  without  tension. 
The  skin  should  be  brought  together  over  the  muscle  and  the  wound 
drained  as  there  is  apt  to  be  some  inflammatory  disturbance. 

Where  sequestra  are  present  it  is  always  desirable  to  remove  them  as 
soon  as  they  have  separated  and  the  involucrum  is  strong  enough  to 
act  as  a  support.  Sequestra  may  be  superficial  or  in  the  mellullary 
cavity  or  both.  Where  there  is  a  persistent  sinus  and  a  sequestrum  is 
present,  pus  will  continue  to  form  until  the  sequestrum  is  removed, 
Cases  discharging  several  years  where  sequestrum  is  present  may  close 
in  a  few  weeks  after  removal  of  the  sequestrum. 

200.  Plastic  Operation  for  Open  Wounds  Following  Osteomyelitis. — 
In  cases  of  chronic  osteomyelitis  when  the  disease  has  practically  sub- 
sided and  the  bone  has  remained  gaping  for  a  long  time,  it  is  sometimes 
very  difficult  to  secure  a  closing  of  the  wound.  Not  only  the  skin  and 
soft  tissues,  but  the  bone  edges  are  sclerosed.  Various  operations  have 
been  devised  to  promote  healing.  The  following  method  is  very  useful. 
Although  used  for  a  long  time  the  writer  has  not  been  able  to  find  the 
physician  responsible  for  the  idea. 

An  incision  is  made  to  one  side  of  the  gaping  wound  down  to  the 
periosteum.  This  is  lifted  from  the  bone  for  the  full  length  of  the  inci- 
sion which  should  be  a  little  longer  than  the  gaping  wound  in  the  bone. 
A  groove  is  cut  in  the  healthy  bone  all  the  way  for  the  full  line  of  incision 
and  down  to  the  medullary  cavity.  When  this  has  been  done  a  sclerosed 
portion  of  the  gaping  bone  should  be  excised  completely  down  to  the 
medulla.  This  leaves  a  long  free  piece  of  bone  between  this  gaping 
wound  and  the  groove.  This  bone  is  displaced  toward  the  gap  in  the 
bone,  completely  closing  it.  The  skin  is  brought  together  loosely  over 
this  and  completely  together  in  certain  places.  The  gap  will  now  be  in 
the  healthy  bone  which  will  gradually  close  after  the  patient  recovers 
from  the  local  reaction  due  to  the  operation.  In  all  these  cases  there  is 
usually  a  slight  septic  reaction  following  the  closure  of  the  infected 
surfaces. 

201.  Methods  and  Principles  of  Drainage  in  Acute  Non-tubercular 
Suppurative  Joint  Disease.  Ankle  and  Foot. — A  small  suppurative 
focus  without  virulence  or  active  constitutional  disturbance  should  be 
drained  by  a  suitable  incision,  wiped  out  with  gauze,  a  tube  placed  to 
its  deepest  part  and  the  soft  tissues  gaped  with  gauze. 

When  there  is  a  great  deal  of  constitutional  disturbance,  drainage  and 


OPERATIONS  IN  SUPPURATIVE  CONDITIONS  175 

counter  drainage  should  always  be  the  rule;  if  the  bone  is  involved  this 
should  be  opened  and  counteropened  as  shown.  The  pus  cavities 
in  the  soft  tissues  should  be  wiped  out.  No  extensive  bone  opera- 
tion should  be  done  otherwise.  The  bone  should  be  drained  with  tubes 
to  the  remote  portions  and  the  muscle,  fat  and  skin  gaped  by  gauze. 
These  operations  are  done  quickly  and  should  not  be  prolonged,  but 
efficient  drainage  and  counter  drainage  should  be  established  unhesi- 
tatingly. It  is  rarely  necessary  to  do  more  at  this  time.  If  there  is 
a  marked  sequestra  formation  this  should  be  removed,  but  this  had  bet- 
ter not  be  done  at  the  time  of  instituting  drainage  when  the  patient  is 
nearly  exhausted  from  an  acute  process.  Any  future  operation  made 
necessary  should  give  good  drainage  and  the  removal  of  the  sequestra 
if  present  and  separated.     See  section  323. 

Any  extensive  non-tubercular  suppurating  bone  disease  about  the 
ankle  should  be  drained  by  two  lateral  anterior  or  two  posterior  incisions 
and,  if  necessary,  an  anterior  median.  If  the  patient  is  very  ill  and  the 
bone  abscess  not  readily  located  the  tissues  are  opened  down  to  the 
bone.    This  should  be  done  very  rapidly  and  good  drainage  established. 

Any  chronic  suppurating  process  should  be  well  drained  and  counter 
drained,  the  pockets  in  the  tissues  well  opened  and  wiped  out  and  the 
diseased  bone  well  drained  in  the  same  way. 


PART  IV-SHOULDER 


CHAPTER  I 


OPERATIONS   FOR   DISLOCATIONS   AND    DEFORMITIES 


202.  Manipulation  of  the  Shoulder  Joint  to  Relieve  Contractures. — 
It  is  important  not  to  manipulate  a  joint  where  there  is  disease,  or  severe 
injury.  Obtaining  motion  under  an  anaesthetic  should  be  done  only 
in  cases  with  limited  motion  where  there  is  no  disease  and  where  the 
limitation  of  motion  is  due  entirely  to  extra  articular  adhesions  or  mus- 
cular contractures  or  very  slight  articular  adhesions. 

In  manipulation  of  the  shoulder  to  relieve  contractures  the  normal 
motion  of  the  joint  should  be  remembered  (see  figures  306  to  313).    The 


Fig.  306,  —  Neu- 
tral position  as  to 
rotation  when  the 
line  between  con- 
dyles of  the  hu- 
merus is  parallel  to 
a  line  between  the 
anterior  superior 
spines  of  the  ilium. 


Fig.  307.— Outward 
rotation  of  the  shoul- 
der. 


Fig.  309.  —  Ab- 
Fig.  308.  —  Ab-  duction  of  the  shoul- 
duction  of  the  shoul-  der  with  outward 
der.  rotation. 


stretching  of  the  resisting  tissues  is  made  gradually, 
then  relaxing,  the  force  being  applied  gently  and  in- 
creased to  a  climax  then  gradually  decreased  until 
there  is  complete  relaxation.  The  blood  is  thus  allowed  to  enter 
and  the  tissues  give  way  and  stretch  with  less  tearing  and  less 
trauma.  A  fair  amount  of  normal  action  in  all  directions  should  be 
obtained  at  the  shoulder  before  any  operation  on  the  muscles;  such  as  a 
muscle  transplantation,  is  done.  A  fair  radius  of  shoulder  motion  is 
present  when  the  fingers  will  reach  the  opposite  scapula,  the  forearm 
passing  in  front  of  the  face  and  the  hand  over  the  shoulder  to  the  scapula; 
second,  the  arm  passing  behind  the  waist  and  upward  to  the  scapula; 
third,  the  arm  passing  behind  the  head  and  neck  and  down  to  the  scapula. 
Outward  rotation  of  the  shoulder  is  very  important.  It  is  easily  lost 
and  often  difficult  to  obtain.  If  the  elbow  is  held  to  the  side  and  flexed 
at  right  angles,  the  shoulder  should  outwardly  rotate  (varying  with  the 

177 


178 


TECHNIQUE  OF  OPERATIONS 


individual)  to  at  least  sixty  degrees  from  a  position  with  the  forearm 
pointing  to  the  front,  the  inward  rotation  including  some  motion  of  the 
scapula  might  reach  one  hundred  and  twenty  degrees.  The  humerus 
will  extend  forward  and  upward  pointing  fifteen  degrees  or  more  back 
from  the  perpendicular  in  standing,  including  some  motion  of  the  scapula. 
The  abduction  (with  a  neutral  position  as  to  rotation)  extends  to 
about  a  right  angle  from  the  side;  after  that  the  scapula  moves  as  the 
elbow  is  raised,  unless  the  shoulder  is  outwardly  rotated.  When  this 
outward  rotation  has  taken  place  the  arm  may  be  abducted  and  raised 
further  until  the  humerus  is  perpendicular  in  standing.  The  amount 
of  adduction  varies  and  may  be  estimated  at  about  thirty  degrees,  vary- 
ing in  the  individual;  combined  motions  are  also  possible.  Extension 
backward  varies  from  thirty  degrees  to  forty-five  degrees.    The  operator 


Fig.  310.— Inward 
rotation  of  the 
shoulder,  the  fore- 
arm lies  across  the 
body. 


Fig.  3  13. —  Ex- 
Fig.    312.  —  Out-    treme    abduction    of 
ward  rotation  of  the    the  shoulder  possible 
shoulder    and   ninety    with     the      humerus 
degrees  of  abduction,    outwardly  rotated. 


Fig.  311.— Abduc- 
tion of  the  shoulder 
with  neutral  position 
as  to  rotation.  No 
further  abduction  is 
possible  without 
moving  the  scapula 

unless  the  shoulder  is  should  try  each  motion  and  gradu- 
outwardiy  rotated.  ally  stretch  until  each  motion  is 
possible,  holding  the  arm  just  below  the  flexed  elbow  and  remembering 
the  tremendous  leverage  possible. 

An  arm  that  has  been  out  of  commission  for  some  time  will  have  a 
very  brittle  bone.  Manipulation  in  such  cases  should  be  done  with  care. 
The  joint  is  gently  stretched  and  relaxed,  the  operator  applying  force 
gently  in  a  gradually  increasing  manner  until  considerable  force  is  ap- 
plied and  finally  relaxing  entirely.  In  this  manner  a  rhythmic  extension 
and  flexion  is  kept  up.  No  rough  or  forcible  extension  without  a  grad- 
ually increasing  or  gradually  decreasing  force  should  be  employed.  By 
this  method  a  minimum  amount  of  trauma  will  be  caused  and  a  joint 
that  at  first  seems  almost  impossible  to  move  will  often  move  consider- 
ably. ^ 

After  obtaining  the  normal  motion  of  the  shoulder  as  completely 
as  possible  by  manipulation,  the  arm  is  put  up  either  straight  up  above 
the  head  and  with  the  elbow  slightly  bent,  or  it  is  put  up  with  the  elbow 
a  little  above  the  shoulder.  This  position  is  maintained  by  a  wire  splint 
(see  figures  314,  315),  or  a  plaster  of  Paris  bandage  including  the  arm 
and  thorax  (see  figures  316,  317,  318).    After  two  to  four  weeks  the  arm 


OPERATIONS  FOR  DISLOCATIONS  AND  DEFORMITIES     179 


is  lowered,  depending  on  the  swelling.  If  the  arm  is  not  put  up  straight 
above  the  head  and  outwardly  rotated,  the  next  best  position  is  that  of 
outward  rotation  and  abduction,  so  that  the  humerus  is  forty-five 
degrees  beyond  right  angle  in  abduction.    It  is  held  this  way  about  two 


Fig.  314. — Wire  arm 
shelf  applied  after  shoul- 
der operations.  (It  may- 
be raised  or  lowered  by 
bending  the  wire.) 


Fig.  315.  —  Wire  arm  shelf, 
showing  straps  for  the  thorax 
and  for  the  arm. 


Fig.  316.  —  Plaster 
applied  after  shoulder 
operations  in   a   posi- 

to    four   weeks,   a   longer   time   if   there  is  much  tion  of  abduction  and 

it  -»«-      i  it  i-  -lii  outward  rotation. 

swelling.    Much  swelling  may  be  avoided  by  care 

in  manipulation,  force  may  be  used  but  not  roughness.    An  ice  bag  is  of 

service  applied  immediately  after  the  operation  if  the  stretching  has 

been  difficult.     In  quiescent  arthritic  cases  this  should  always  be  done. 

After'  the  first  two  weeks  if  there  is  no  swelling,  the  arm  is  lowered 

so  that  the  humerus  is  horizontal,  i.  e.,  ninety  degrees  of  abduction 

and  forty-five  degrees  of  outward  rotation,  the 

forearm  with  the    elbow  at    right   angles.    This 

position  is   maintained   by  a  wire  splint  in  the 

form  of  a  shelf  (see  figures  314  and  315).    The 

wire  is  bent  and  lowered  as  the  case  improves. 

The  arm  is  strapped  to  it  allowing  the  use  of  the 

elbow,  wrist  and  hand  without  removing  the  shelf. 

As  the  patient  learns  to  exercise  the  muscles  of 

the  fingers,  forearm  and  upper  arm  on  the  shelf, 

he  is  able  later  to  lift  the  arm  above  the  shelf. 

With  improvement  in  strength  the  shelf  is  lowered     ,.Fl,G-  317.— Plaster  ap- 

i„£fj.j  -j.j  !?ti.l-  i    phed  after  shoulder  op- 

to  fifty  degrees  or  sixty  degrees  of  abduction  and  erations  in  a  position  of 

used  this  way  for  six  to  ten  months  depending  on  ninety  degrees  abduction 

the  strength  of  the  arm.  Much  of  the  exercise  a° ^aet^al  position  a3 
each  day  should  be  done  with  the  humerus  held 

abducted  sixty  degrees  and  resting  on  such  a  shelf  or  table  dur- 
ing the  exercise.  Later  the  exercise  is  repeated  daily  without  the 
shelf. 


180 


TECHNIQUE  OF  OPERATIONS 


203.  Operations  to  Correct  Permanent  Inward  Rotation  of  the 
Upper  Arm. — Inward  rotation  of  the  shoulder,  when  not  due  to  a 
joint  condition,  is  caused  by  a  relaxed  condition  of  the  posterior  out- 
ward rotators  of  the  shoulder  or  a  tense  condition  of  the  inward  rota- 
tors. This  may  be  actual,  as  in 
spastic  cases,  or  comparative  as 
in  infantile  paralysis.  Sometimes 
with  the  primary  cause  there  co- 
exists adhesions  and  tissue  short- 
ening and  sometimes  depression  of 
the  acromium  that  must  be  taken 
into  account.  When  there  is  a 
bony  change  that  prevents  correc- 
tion of  the  deformity  it  will  usually 
appear  on  palpation  or  in  the  x-ray 
or  both. 

In  slight  cases,  the  outward  rota- 
tion may  be  secured  by  reefing  the 
posterior  capsule  which  practically 
tightens  up  the  infra-spinatus  mus- 
cle. If  this  muscle  is  good  the 
benefit  will  be  more  than  tem- 
porary. Where  the  contracture  is 
extreme,  this  will  not  be  sufficient. 
The  condition  may  also  be  re- 
lieved by  lengthening  the  attach- 
ment of  the  pectoralis  major,  which 
is  slit  and  overlapped  as  described 
elsewhere  in  these  pages  or  by  an 
osteotomy  through  the  upper  or 
lower  third  of  the  humerus,  the 
lower  fragment  being  outwardly 
rotated  and  allowed  to  heal  in 
this  position.  In  the  obstetrical 
paralysis  cases  and  certain  spastic 
cases  the  best  results  are  obtained 
by  a  myotomy  of  the  pectoral  and 

Fig.  318.— Plaster  cuirass  used  after  opera-   0f  the  Sllbscapularis  suggested  by 
tion  on  the  shoulder.  ^     g^.     ^     ^     ^^     ^ 

scapula  to  flatten  into  position.     Often  an  osteotomy  of  the  acromium 
is  necessary  beside. 

204.  Osteotomy  of  the  Humerus  to  Correct  Inward  Rotation  of 
the  Shoulder. — The  patient  lies  on  his  back,  being  placed  close  to  the 
opposite  edge  of  the  operating  table.  The  operator  stands  on  the  side 
of  the  arm  to  be  operated  on.  The  assistant  stands  to  his  right  holding 
the  forearm  with  flexion  at  the  elbow.     See  figures  494-496. 


OPERATIONS  FOR  DISLOCATIONS  AND  DEFORMITIES    181 


An  incision  is  made  one  inch  long,  just  above  the  junction  of  the  upper 
and  middle  third  of  the  outer  aspect  of  the  upper  arm,  or  in  the  upper 
part  of  the  lower  third.  The  skin  is  incised  and  retracted;  the  fat  and 
the  muscle  fibers  are  separated  by  a  blunt  dissector,  and  retracted,  ex- 


Fig.  319. — Double  many  tail  swathe  used  behind  the 
plaster  cuirass. 

posing  the  bone.    A  very  small  incision  is 

11    ,i     ,     •  a  j.    -j.  ■  Fig.   320. — Manner   of   com- 

all  that  is  necessary.    An  osteotome  is  ap-  bining  the  plaster  in  front  with 

plied  to  the  bone  the  double  many  tail  swathe  be- 
fsee  fiffure  321 )  mnd  an<^  with  the  plaster  arm 
f,    .  ...         i        above.     Notice  the  plaster  rope 

-Before  CUttmg  the  used  to  re-enforce  the  plaster 
bone      COmpletelv  and    incorporated    in    its    deep 

through,  the  sur-  layers- 
geon  assures  himself  that  his  assistant  is 
steadying  the  elbow  and  forearm  in  order  to 
allow  practically  no  displacement  and  no 
trauma  when  the  bone  is  cut  through.  After 
completing  the  cut  in  the  bone,  the  wound  is 
closed  by  one  or  two  deep  catgut  sutures, 
number  00,  including  the  skin.  Five  layers 
of  gauze  just  covering  the  incision  are  ap- 
plied as  a  dressing,  over  this  rollers  of  sterile 
sheet  wadding.  The  sterile  sheet  wadding 
rollers  are  applied  gently  and  carefully  in 
order  to  prevent  any  jarring  or  displacement 
of  the  bone.  Coaptation  splints  are  next 
applied  as  seen  in  figure  322.  When  the 
coaptation  splints  are  snugly  fastened,  the 

FlG'  321th^0humterue   CUttinS  arm  is  next  Sently  rotated  outward  about 

thirty  degrees.  This  thirty  degrees  is  esti- 
mated from  a  position  in  which  the  forearm  points  to  the  front  with  the 
elbow  at  the  side.  A  plaster  of  Paris  bandage  is  applied  holding  the  arm 
and  forearm  at  right  angles  (see  figure  323).  Over  this  a  snug  swathe  is 
applied  holding  the  plaster  at  the  shoulder  and  the  elbow  to  the  side 
(see  figure  324).     An  internal  angular  splint  over  the  coaptation  splint, 


182 


TECHNIQUE  OF  OPERATIONS 


a  shoulder  cap,  an  axillary  pad,  a  swathe  in- 
cluding the  chest  and  affected  arm  may  be  sub- 
stituted for  the  plaster,  the  outward  rotation  of 
the  shoulder  in  this  instance  is  maintained  by 


Fig.  323. — A  plaster  of  Paris  bandage  and  axillary 
pad  applied  over  the  coaptation  splints. 


Fig.  322.— Sheet  wadding 
applied  without  disturbing 
the  arm.  Coaptation  splints 
applied  before  disturbing 
the  cut  bone. 


Fig.  324. — Swathe  applied  over  the  thorax  and  arm. 

the  use  of  adhesive  straps  looped  around  the  fore- 
arm over  the  apparatus  and  over  the  outside  of  the 
swathe  instead  of  being  placed  on  the  skin.  Two 
adhesive  straps  are  applied  separately  extending  from 
the  shoulder  to  the  back  and  two  straps  applied 
separately  from  the  shoulder  to  the  front  of  the  chest, 
and  two  from  the  elbow,  one  in  front,  and  one  behind 
the  thorax. 

Excellent  results  are  obtained  from  this  operation. 


Fig.  325.  —  Splint 
and  belt  to  prevent 
inward  rotation  of  the 
shoulder,  showing  ex- 
tension of  the  elbow. 
There  is  no  limitation 
of  flexion  or  extension 
of  the  elbow. 


OPERATIONS  FOR  DISLOCATIONS  AND  DEFORMITIES     183 


The  pain  suffered  is  practically  nothing  if  the  dressing  is  comfortably 
applied.     There  is  little  or  no  swelling. 

After  treatment 

The  patient  should  be  kept  in  bed  about  ten  days  using  a  low  bed 
rest  constantly.     The  bed  rest  is  raised  for  meals  after  the  first  week. 

C 

0$M 


Fig.  328.— Splint  and  belt  to  pre- 
vent inward  rotation  of  the  shoulder. 

A,  Plate  to  prevent  inward  rotation. 

B,  Joint  allowing  flexion  and  exten- 
sion of  the  elbow  and  outward  rota- 
tion of  the  shoulder.  C,  Leather  cuff 
for  upper  arm.  D,  Leather  cuff  for 
forearm.    E,  Belt. 


Fig.  326.— Splint 
and  belt  to  prevent  in- 
ward rotation  of  the 
shoulder,  showing  out- 
ward rotation  of  the 
shoulder. 


Fig.  327.— Splint 
and  belt  to  prevent  in- 
ward rotation  of  the 
shoulder,  with  the 
shoulder  rotated  to  a 
neutral  position. 


Fig.  329.— Splint  and  belt  to 
prevent  inward  rotation  of  the 
shoulder,  inner  view. 


The  outward  rotation  is  maintained  for  six  or  eight  weeks  allowing  use 
of  the  hand  in  the  third  week. 

The  apparatus  is  removed  a  little  each  day  after  the  sixth  week.  If 
the  union  is  soft  the  apparatus  should  remain  longer.  After  the  eighth 
week  the  apparatus  is  worn  part  of  each  day  and  a  belt  apparatus 
maintains  the  outward  rotation  of  the  shoulder  and  allows  the  use  of 
the  arm  and  hand.  It  consists  of  a  metal  semicircle  fastened  to  a  belt 
preventing  the  inward  rotation  of  the  shoulder  (see  figures  325,  326,  327, 
328  and  329).  The  humerus  is  fastened  by  a  cuff  to  the  belt  pre- 
venting abduction  of  the  arm.  A  wrist  cuff  is  attached  to  a  metal  arm 
which  strikes  the  aluminum  semicircle  and  checks  inward  rotation. 
This  apparatus  is  worn  for  the  whole  or  part  of  the  day  over  the  clothes. 
In  extreme  cases,  apparatus  is  necessary  for  a  year,  muscle  stretching 


1S4 


TECHNIQUE  OF  OPERATIONS 


and  muscle  training  should  be  done  twice  daily  as  long  as  there  is  any 
tendency  of  the  muscles  to  recontract. 

205.  Osteotomy  for  a  Depressed  Acromium. — When  the  acromium 
is  depressed  in  certain  paralytic  conditions  of  the  shoulder  and  in 
children  with  total  or  partial  dislocation  of  the  shoulder  of  long  stand- 
ing, the  head  of  the  humerus  will  be  found  slightly  out  of  place  and  a 
limitation  of  motion  caused  from  the  deformity  of  the  acromium.  This 
turning  over  is  demonstrable  by  the  x-ray  but  may  be  easily  felt. 

An  osteotome  is  used  to  incise  the  skin  one  and  one-half  inches 
from  the  tip  of  the  acromium,  a  subcutaneous  osteotomy  of  the  acro- 
mium, is  done,  allowing  the  depression  to 
be   corrected  and  the   humerus  to   slide 


Fig.  330. — Deltoid  fibers  retracted 
showing  fatty  layers  over  the  cap- 
sule. 


Fig.  331. — Sutures  quilted  into  the  capsule. 


into  place.  .  The  incision  may  need 
one  suture.  The  shoulder  is  held  out- 
wardly rotated  ninety  degrees  and 
abducted  ninety  degrees  for  six  weeks. 

During  the  healing  of  the  fracture, 
other  treatment  is  sometimes  necessary 
when  the  condition  accompanies  ob- 
stetrical or  infantile  paralysis. 

206.  Muscle  Shortening.  Opera- 
tion for  Shortening  the  Infra  Spinatus 
to  Correct  Inward  Rotation  of  the 
Shoulder. — The    patient    lies   on    his 

back,  a  hard  pillow  Or  sand  bag  lifts  FlG-  332 —Capsule  drawn  tight  after 
.,  .   ,  .       -ip,!        ,i  jij  rotating  the  shoulder  outward. 

the  right  side  ot  the  thorax  so  that 

the  scapula  does  not  touch.  After  stretching  the  shoulder  in  outward 
rotation,  sterile  protection  is  used  leaving  the  shoulder  exposed  above 
and  posteriorly  as  well  as  laterally  and  anteriorly. 

An  incision  three  inches  long  is  made  through  the  skin  and  fat  from  the 
tip  of  the  acromium  backward  and  outward  parallel  to  the  outer  fibers 
of  the  deltoid  (figure  330) ;  the  deltoid  fibers  are  next  separated  with  a 


OPERATIONS  FOR  DISLOCATIONS  AND  DEFORMITIES     185 

blunt  dissector  exposing  the  thin  fatty  layer  over  the  capsule;  this  is 
followed  downward.  A  double  set  of  mattrass  sutures  are  quilted  into 
the  capsule  and  infra  spinatus  tendon  which  is  continuous  with  it  (figure 
331).  The  shoulder  is  outwardly  rotated  as  far  as  possible  and  each  of 
the  sutures  tightened  and  tied  (figure  332),  maintaining  the  outward 
rotation.  The  arm  is  held  in  an  outwardly  rotated  position  by  means  of 
plaster  of  Paris  or  a  wire  splint  (see  figures  314  to  317).  This  operation 
is  recommended  by  Professor  Vulpius  and  others  for  persistent  inward 
rotation  of  the  shoulder  (see  Osteotomy).     Section  204. 

207.  Muscle  Lengthening  to  Correct  Partial  or  Total  Permanent 
Rotation  of  the  Shoulder. — When  the  inward  rotation  of  the  shoulder 
is  due  to  the  short  or  contracted  pectoral  muscle  the  subscapularis 
will  usually  be  found  short  also.  This  may  be  demonstrated  by  out- 
wardly rotating  the  humerus.  When  this  is  performed  the  axillary 
border  of  the  scapula  will  come  forward.  The  latter  may  be  cut  across 
at  its  attachment  or,  as  recommended  by  Dr.  Sever,  away  from  the 
capsule.  The  lengthening  of  the  pectoralis  muscle  should  be  done  in 
its  outer  portion.  The  fibers  are  cut  across  diagonally  and  sutured, 
or  in  a  dentated  manner  as  shown  in  figures  201,  202  and  then 
sutured.  The  humerus  should  be  placed  in  a  position  of  ninety  degrees 
of  abduction  and  ninety  degrees  of  outward  rotation  and  held  there  for 
six  weeks  (see  figure  316).  After  the  third  week  the  arm  is  put  on  a 
wire  splint  (see  figures  314  and  315)  and  passive  motion  applied  twice 
a  day.  After  six  weeks  the  arm  is  used  on  a  shelf  holding  it  adducted 
sixty  degrees.  The  position  of  extreme  outward  rotation  should 
be  maintained  for  six  or  eight  weeks,  allowing  the  use  of  the  wrist  and 
hand  after  the  first  week.  At  the  end  of  six  weeks  the  apparatus  is  re- 
moved twice  daily  for  twenty  minutes.  The  time  is  extended  every 
three  days  until  it  is  removed  six  hours  a  day.  After  that  the  splint  is 
used,  maintaining  extreme  outward  rotation  for  two  hours  daily  for  a 
year.  Exercises  and  muscle  training,  especially  in  outward  rotation, 
should  be  done  for  several  years,  depending  on  the  tendency  of  the 
deformity  to  recur. 

208.  Operation  for  Inward  Rotation  of  the  Shoulder  in  Obstetrical 
Paralysis  and  other  Conditions.  Myotomy  of  the  Subscapulars  and 
of  the  Pectoralis  Muscles.  Dr.  Sever's  Operation. — In  inward  rota- 
tion of  the  shoulder  due  to  obstetrical  paralysis  a  certain  number  of 
cases  cannot  be  benefited  by  conservative  treatment.  It  is  necessary 
to  myotomize  the  pectoralis  major  and  subscapularis  muscles.  When 
this  is  done  the  tendency  to  round  shoulders  and  paralysis  of  all  other 
muscles  of  the  shoulder  due  to  the  contracture  can  often  be  prevented. 
The  scapula  fits  back  into  place  and  the  other  muscles  develop  often 
to  a  surprising  degree.  After  cutting  the  pectoralis  major  the  surgeon 
may  feel  that  he  has  done  enough,  but  he  will  find  that  in  outwardly 
rotating  the  humerus  the  scapula  will  come  forward  into  the  axilla. 
After  cutting  the  subscapularis  this  will  not  take  place. 


186  TECHNIQUE  OF  OPERATIONS 

This  operation  may  be  done  also  in  cases  of  cerebral  paralysis  that 
have  the  deformity. 

The  arm  is  abducted  and  outwardly  rotated.  An  incision  is  made 
from  the  acromium  downward  and  outward  between  the  deltoid  and  the 
pectoralis  major  muscles.  When  these  muscles  have  been  separated  with 
a  blunt  dissector  the  fibers  of  the  pectoral  are  lifted  on  a  director  and  cut 
across,  unless  the  operator  decides  to  lengthen  them  as  described  else- 
where in  these  pages.  The  under  fibers  of  the  pectoralis  tendon  are  tough 
and  fibrous.     These  should  be  cut  as  well  as  the  muscle  fibers. 

The  shoulder  should  now  easily  rotate  outward,  but  if  the  operator 
stops  here  he  will  find  that  a  troublesome  inclination  forward  of  the 
scapula  will  persist  when  the  child  grows  older.  The  outer  border  of 
the  scapula  and  its  angle  will  be  found  to  come  forward  into  the  axilla 
as  the  shoulder  is  outwardly  rotated.  To  avoid  this  Dr.  Sever  has 
suggested  cutting  the  subscapularis  in  its  tendon  away  from  the  cap- 
sule. The  humerus  is  outwardly  rotated,  bringing  the  subscapularis 
tendon  into  view,  it  is  attached  high  up  in  the  inner  border  of  the 
bicipital  groove  and  is  continuous  with  the  fibers  of  the  capsule.  At 
this  point  a  few  muscular  fibers  extend  here  almost  to  the  bicipital 
groove.  The  writer  has  incised  the  fibers  here  at  the  outer  edge  of  the 
bicipital  groove.  This  should  not  be  done  until  the  tendon  has  been 
traced  to  its  attachment  here.  When  it  is  cut  the  humerus  may  be 
outwardly  rotated  without  bringing  the  scapula  forward  into  the  axilla. 

The  deep  and  superficial  tissues  are  closed  with  interrupted  catgut, 
the  skin  with  continuous  catgut  sutures.  The  shoulder  is  held  ab- 
ducted ninety  degrees;  outwardly  rotated  ninety  degrees  with  the  elbow 
at  right  angles.  A  plaster  is  applied  as  shown  in  figure  316,  including 
the  thorax  and  arm.  The  plaster  is  bivalved  so  that  the  upper  por- 
tion of  the  shoulder  and  arm  plaster  is  removable,  allowing  the  arm  to 
slide  out  and  be  manipulated  after  the  second  week;  in  three  or  four 
weeks  a  wire  splint  is  used  (see  figures  314,  316),  allowing  the  arm  to  be 
used  and  manipulated  so  that  there  will  be  no  danger  of  stiffness.  At 
the  end  of  three  months  the  shoulder  shelf  is  gradually  discarded,  being 
used  two  hours  a  day  for  one  year  after  that. 

This  operation  by  relieving  the  strongly  contracted  muscles  in  ob- 
stetrical paralysis  will  allow  the  arm  to  grow  in  strength  and  usefulness, 
which  is  not  possible  otherwise.  The  muscles  and  use  of  the  arm  must 
be  trained  daily. 

209.  Operation  for  Inward  Rotation  of  the  Arm  in  Spastic  Paralysis. 
— In  certain  spastic  paralysis  cases  the  inward  rotation  of  the  shoulder 
is  very  similar  to  that  seen  in  obstetrical  paralysis.  In  these  cases  it  is 
often  of  advantage  to  cut  the  pectoral  and  the  subscapularis  muscles  to 
allow  free  outward  rotation  of  the  shoulder  without  causing  the  outer 
border  of  the  scapula  to  move  forward  into  the  axilla. 

The  operation  is  described  in  these  pages  for  obstetrical  paralysis. 
The  after  treatment  is  the  same.     See  sections  207,  208. 


OPERATIONS  FOR  DISLOCATIONS  AND  DEFORMITIES     187 


210.  Dislocation  of  the  Clavicle. — A  dislocation  of  the  clavicle  of 
long  standing  will  require  an  incision  along  the  end  dislocated,  often  the 
sternal  end.  A  sand  bag  is  placed  between  the  shoulder  blades  and 
the  chest  held  well  up,  expanded  over  pillows,  with  the  head  held 
back. 

This  position  is  obtained  before  operation.  The  clavicle  is  exposed 
and  the  end  loosened  up  subperiosteally,  the  shoulder  hyperextended 
and  the  clavicles  will  readily  slip  in  place. 

If  the  loosening  of  the  tissues  does  not  complete  reduction  a  small  por- 
tion of  bone  is  removed.  The  bone  is  freshened  and  drilled  before  re- 
duction and  held  in  place  by  heavy  silk  or  by  silver  wire.  A  Sayre 
apparatus  is  applied  as  for  fracture  of  the  clavicle  or  a  plaster  of  Paris 
jacket  or  posterior  shell  is  used  or  a  Sayre  clavicle  brace. 

The  treatment  is  the  same  as  for  fracture  of  the  clavicle. 

211.  Partial  Dislocation  of  the  Shoulder  due  to  Paralysis,  often 
in  Obstetrical  Paralysis  with  or  without  Depression  of  the  Acromium. 
— In  dislocation  of  the  shoulder  due  to  paralysis  of  the  muscles,  the 
capsule  must  often  be  reefed,  the  shoulder  outwardly  rotated  and  ab- 
ducted ninety  degrees  and  held  on  a  wire  shelf  while  the  partly  paralyzed 
muscles  are  relieved  of  strain  and  weight-bearing  and  are  exercised  in 
this  position  for  months.  Good  action  of  the  shoulder  is  often  prevented 
and  the  dislocation  maintained  by  a  depression  of  the  acromium,  this 
with  the  long  capsule  favor  the  dislocation.  The  depressed  acromium 
is  cut  across  at  the  root  by  an  osteotome  and  the  capsule  reefed  by 
quilted  sutures.  The  arm  is  then  held  as  above  described  for  five 
weeks  during  the  healing  of  the  fracture  and  afterward  as  long  as 
it  is  necessary  to  allow  the  muscles  to  be- 
come strong.     See  sections  205,  214. 

212.  Partial  Dislocations  of  the  Shoul- 
der in  Paralytic  Conditions.  — In  condi- 
tions of  partial  dislocation  of  the  shoulder 
in  obstetrical  paralysis  and  other  paralytic 
conditions  of  the  deltoid,  the  capsule  is 
abnormally  long  allowing  a  displacement 
of  the  humerus. 

The  dislocation  may  be  replaced  and  a 
few  quilted  sutures  stitched  into  the  cap- 
sule in  such  a  way  as  to  pucker  the  cap- 
sule and  shorten  it  (see  figure  333) .  See 
section  214. 

This  will  suffice  unless  the  dislocation  is 
of  long  standing  and  the  acromium  has 
become  depressed  in  which  case  this  de-        FlG-  333.— Capsulorrhapy. 
formity  should  be  remedied  at  the  same  time  by  an  osteotomy.     See 
section  205. 


18S  TECHNIQUE  OF  OPERATIONS 

213.  Open  Operation  in  Cases  of  Irreducible  Dislocation  of  the 
Shoulder. — A  dislocation  of  the  shoulder  should  be  reduced  by  the 
usual  manipulation;  when  it  does  not  yield  to  this  as  in  certain  recent 
and  in  dislocations  of  long  standing  the  open  operation  is  indicated. 
An  anterior  incision  or  a  Kocher  incision  may  be  used,  preferably  the 
anterior  enlarged  as  described  under  arthrotomy. 

In  any  so-called  irreducible  dislocation,  the  operator  may  make  an 
attempt  to  reduce  the  dislocation  by  the  usual  methods  before  using 
the  open  operation;  when  there  is  evidence  of  adhesions  or  the  dis- 
location is  of  long  standing,  after  a  well  applied  attempt  an  operation 
should  be  resorted  to  at  once,  in  order  to  save  time  and  not  exhaust 
the  patient.  Extensive  manipulations,  especially  in  the  old,  are  unde- 
sirable when  an  open  operation  is  probable. 

In  some  cases  an  excision  is  necessary  either  because  reduction  is 
impossible  or  the  head  is  held  too  tightly  by  the  contracted  tissues. 
In  dislocations  of  long  standing  where  the  joint  cavity  and  head  are  in- 
jured and  where  reduction  without  tension  may  be  effected  an  excision 
is  not  indicated. 

Generally  if  the  bone  adjoining  the  head  is  well  cleared  subperiosteal^ 
an  excision  may  be  avoided.  A  subglenoid  dislocation  of  five  years'  stand- 
ing may  be  reduced  by  this  method  without  excision. 

The  Burrell  incision  (figure  362)  is  a  very  useful  one  for  these  cases. 
It  is  necessary  in  these  cases  after  opening  the  glenoid  cavity  which  will 
be  found  much  retracted,  to  replace  the  head  and  overlap  the  muscles 
in  such  a  way  as  to  complete  the  capsule  where  it  is  lacking.  In  some 
cases  the  very  much  lengthened  muscles  must  be  allowed  to  contract. 
For  this  purpose  the  elbows  and  forearm  should  be  well  padded  and  held 
by  adhesive  plaster  straps  to  the  opposite  shoulder  so  that  no  weight 
will  come  on  the  sutured  capsule  and  the  muscles.  The  relief  of  pain 
following  the  operation  is  usually  immediate. 

214.  Capsulorrhapy  for  Dislocation  of  the  Shoulder  in  Paralytic 
Conditions. — The  dislocation  in  paralytic  conditions,  when  it  is  not 
traumatic,  is  usually  due  to  a  long  relaxed  capsule.  The  lack  of  muscle 
and  tissue  tone  has  allowed  the  capsule  to  be  dragged  out  until  it  is  too 
long. 

An  incision  is  made  parallel  to  the  inner  border  of  the  deltoid  and  one- 
half  inch  from  it.  The  deltoid  fibers  are  separated  and  the  capsule  is 
exposed,  the  arm  is  outwardly  rotated  ninety  degrees  and  abducted 
ninety  degrees,  two  or  three  sets  of  quilted  sutures  are  placed  in  the 
capsule  in  such  a  way  as  to  pucker  it  and  as  the  sutures  are  drawn  and 
tied  this  will  remedy  the  lax  condition.  The  arm  is  held  on  a  wire  shelf 
and  the  muscles  exercised  and  strengthened  on  it  for  six  to  ten  months 
depending  on  the  amount  of  paralysis. 

215.  Operation  for  Recurrent  Dislocation  of  the  Shoulder. — In 
recurrent  dislocation  of  the  shoulder  an  incision  is  made  between  the 
pectoralis  major  and  the  deltoid  extending  inward  one-half  inch  below 


OPERATIONS  FOR  DISLOCATIONS  AND  DEFORMITIES    189 

the  clavicle.  The  joint  is  reached  and  the  tear  in  the  capsule  located 
by  a  complete  exposure  of  the  joint.  When  the  capsule  is  not  easily- 
closed,  silk  may  be  quilted  across  or  the  capsule  released  from  the 
humerus  subperiosteally  and  the  tear  is  sutured  with  silk.  The  suture 
should  not  limit  motion  in  outward  rotation;  for  this  reason  the  humerus 
is  outwardly  rotated  while  the  sutures  are  being  placed. 

No  motion  in  abduction  of  the  shoulder  should  be  allowed  for  at  least 
four  weeks.  But  slight  motions  are  allowed  in  other  directions  especially 
in  outward  rotation  after  the  tenth  day. 

216.  Operation  for  Congenital  High  Position  of  the  Scapula  or 
Sprengel's  Deformity. — An  incision  is  made  along  the  vertebral  border 
of  the  scapula  down  to  the  bone;  as  the  edge  of  the  scapula  is  reached  an 
osteotome  is  used  to  lift  the  muscles  subperiosteally  from  its  inner  border 
upward  and  the  muscles  from  the  upper  border.  That  part  of  the 
scapula  above  the  spine  which  is  often  folded  over  should  be  chiselled 
away  and  removed.  When  the  muscles  are  detached  subperiosteally 
from  the  under  side  and  upper  end  of  the  scapula  by  a  subperiosteal 
dissection,  using  a  long  handled  osteotome,  the  scapula  will  be  released 
and  may  be  depressed  and  if  necessary  held  in  position  to  the  rib  by  a 
long  chromic  catgut  suture  number  one. 

A  plaster  of  Paris  bandage  is  used  to  hold  the  arm  and  thorax. 

217.  Application  of  Plaster  of  Paris  Bandage  to  the  Shoulder. — In 
applying  the  plaster  of  Paris  bandage  to  the  shoulder,  the  plaster  should 
be  low  on  the  side  of  the  chest  of  the  affected  shoulder;  it  should  be  very 
narrow  and  high  on  the  chest  under  the  opposite  shoulder.  It  may 
reach  over  both  shoulder  or  include  only  the  affected  or  the  well  shoulder 
but  it  should  include  the  humerus  and  forearm  of  the  affected  side  (see 
figures  316,  317). 

There  should  be  a  good  deal  of  padding  low  down  on  the  chest  below 
the  axilla  of  the  affected  side,  also  about  the  elbow  and  axilla.  The 
elbow  is  usually  held  at  right  angles  in  order  to  maintain  the  necessary 
rotation.  The  plaster  is  halved  so  that  the  upper  portion  may  be  re- 
moved from  the  arm  and  forearm  allowing  the  shoulder  to  be  inspected  or 
manipulated.  The  chest  portion  of  the  plaster  is  bivalved  so  that  the 
front  or  back  may  be  removed.  This  part  of  the  plaster  can  be  laced 
as  shown  in  figures  436  to  440. 


CHAPTER  II 

MUSCLE   AND   TENDON   OPERATIONS.      -MUSCLE  AND   TENDON 
TRANSPLANTATION. 

218.  Operation  for  Paralysis  of  the  Triceps,  Transplantation  of  the 
Deltoid. — When  the  triceps  is  paralyzed  and  the  deltoid  remains  good, 
a  long  vertical  incision  is  made  over  the  outer  border  of  the  deltoid  down 
to  the  junction  of  the  middle  and  lower  third  of  the  arm.  The  incision 
is  made  in  the  outer  third  of  the  posterior  aspect  of  the  upper  arm. 


Fig.  334. — Triceps  dissected  up. 

The  tissues  are  retracted  exposing  the  deltoid.  One-half  or  two- 
thirds  of  the  upper  fibers  of  the  triceps  are  removed  from  their 
attachment  and  attached  to  the  posterior  half  of  the  deltoid  which 
is  freed  as  low  as  possible.  The  upper  end  of  the  triceps  is  de- 
tached from  the  humerus.    The  fibers  are  scarified  superficially  on 


Fig.  335. — Split  deltoid  transplantation  to  the  paralyzed  triceps. 

both  sides.  The  posterior  half  of  the  deltoid  muscle  to  be  trans- 
planted is  divided  into  two  halves  (see  figures  334  and  335).  The 
fibers  of  the  triceps  are  quilted  with  silk,  quilted  sutures  are  placed 
in  each  part  of  the  slit  deltoid,  one  set  in  each  half  that  has  been 
divided.  The  slit  in  the  deltoid  receives  the  triceps,  one-half  going 
anterior,  the  other  posterior.    The  muscles  are  held  together  by  these 

190 


MUSCLE  AND  TENDON  OPERATIONS 


191 


quilted  silk  sutures  and  other  mattrass  sutures.  The  deltoid  muscle  is 
superficially  scarified  before  being  attached  to  the  triceps.  A  plaster  or 
wire  splint  is  applied  holding  the  elbow  straight  or  in  a  few  degrees  of 
flexion  and  a  large  wedge  pad  in  the  axilla;  a  swathe  is  applied  including 
the  arm  and  thorax.  A  window  is  cut  over  the  posterior  part  of  the 
plaster  which  allows  inspection  of  the  incision.     The  after  treatment 


r 


Fig. 


336. — Incision    over   the   trapezius 
and  deltoid. 


Fig.  337.- — Part  of  the  trapezius  cut  from  its 
insertion  and  dissected  up. 


consists  of  absolute  rest  for  two  weeks  in 
bed  on  an  incline  with  a  low  bed  rest. 

The  arm  is  kept  extended  six  weeks  and 
gradually  flexed  but  not  more  than  twenty 
degrees  beyond  a  right  angle  position  for 
over  six  months.  Muscle  training  and  ex- 
ercises at  home  should  be  employed  daily 
for  at  least  a  year. 

219.  Transplantation  of  the  Trapezius 
to  the  Deltoid  for  Paralysis  of  the  Del- 
toid.— In  operation  on  the  right  shoulder, 
the  patient  lies  on  his  back  with  a  large 
sand  bag  or  hard  pillow  under  the  right 
shoulder  so  that  the  shoulder  and  scapula 
are  held  off  of  the  operating  table.  The 
operator  stands  above  the  shoulder. 

A        •      •  •  j         i  J.T-         j  r       Fig.  338. — The  upper  arm  ab- 

An  incision  is  made  along  the  edge  of  ducted  and  outwardl£  rotated  t0 

the  trapezius  to  the  acromion  process.     The  allow  the  insertion  of  the  trapezius 

skin  and  fat  are  dissected  in  one  layer  and  mto  the  delt0ld- 
retracted,  exposing  the  trapezius  muscle  (see  figures  336  to  341).  Part  of 
its  clavicular  and  scapula  insertion  is  dissected  up  and  carried  outward 
to  the  deltoid.  Before  insertion,  both  the  deltoid  and  the  trapezius 
muscle  fibers  are  scarified  superficially.  The  trapezius  is  quilted  up  one 
side  and  down  the  other  with  silk  sutures  and  attached  to  the  upper 


192 


TECHNIQUE  OF  OPERATIONS 


end  of  the  deltoid  which  is  freed  and  the  silk  is  quilted  into  it.  Mattress 
sutures  are  also  placed  into  the  overlapping  muscles.  The  shoulder 
should  be  flexed  and  raised  (figure  316).    The  elbow  is  at  the  height  of 


Fig.  339. — The  trapezius  su- 
tured to  the  deltoid  and  then  the 
paralyzed  deltoid  sutured  over- 
lapping the  trapezius. 


Fiq.  340. — Suture  of  the  subcu- 
taneous tissues. 


the  shoulder  and  held  in  this  way  during  and 
after  the  transplantation.  The  deep  tissues 
are  brought  together  with  interrupted  chromic 
catgut  sutures  number  00,  the  skin  with  con- 
tinuous chromic  catgut  sutures  number  00. 
The  abduction  is  ninety  degrees,  the  outward 
rotation  forty-five  degrees. 

The  position  is  maintained  as  seen  in  fig- 
ure 317,  by  a  plaster  of  Paris  bandage  extend- 
ing over  the  chest  and  arm.  A  wire  splint 
replaces  the  plaster  at  the  end  of  two  weeks. 
The  plaster  is  preferable  at  the  time  of  the 
operation  as  it  will  be  more  comfortable  and 
allow  less  motion. 

The  after  treatment  is  the  same  as  that 
prescribed  for  transplantation  of  the  trape- 
zius to  half  of  the  pectoralis  major.  See  sec- 
tion 241. 

220.  Operation  for  Paralysis  of  the  Del-  sutures. 
toid.    Transplantation  of  the  Trapezius  to  Part  of  the  Pectoralis  Major 
Insertion. — To  transplant  the  trapezius  to  half  of  the  insertion  of  the 
pectoralis  major,  the  patient  lies  on  his  back,  the  operator  stands  on  the 
side  on  which  the  operation  is  to  be  done. 

An  incision  is  made  one  inch  above  the  lower  edge  of  the  pectoralis 


Fig.   341. — Incision    sutured 
with  continuous  or  interrupted 


MUSCLE  AND  TENDON  OPERATIONS 


major  and  parallel  to  it.  The  incision  extends  from  the  humerus  four 
inches  inward  through  the  skin  and  subcutaneous  fat.  These  are  re- 
tracted. A  broad  portion  of  the  lower  edge  of  the  muscle  is  detached 
from  the  rest  of  the  muscle;  the  fibers  are  separated  from  within  out- 
ward (see  figures  342,  343).  When  the  tendon  is  reached  it  is  slit  longi- 
tudinally. The  muscle  thus  separated  is  reflected  upward  toward  the 
shoulder;  it  is  still  attached  to  the  humerus  by  one-half  of  the  tendon. 


Fig.  342. — Exposure  of  the  pec- 
toralis  major. 


Fig.  343.— One-half  of  the  pec- 
toralis  major  ready  to  be  attached 
to  a  portion  of  the  trapezius. 


Fig.    344.  —  Posterior   view, 
posure  of  the  trapezius. 


Fig.  345. — Posterior  view.     The  trapezius  cut 
Ex-  away   from    its    insertion,    ready   for   silk  su- 

tures. 


The  separated  muscle  is  raised,  and  a  towel  placed  on  the  arm  above  and 
another  below  while  two  or  three  sets  of  quilted  silk  sutures  are  inserted 
into  its  fibers.  The  breakage  of  the  silk  should  be  tested  before  inserting 
it  into  the  muscle. 

A  second  incision  is  made  along  the  anterior  border  of  the  trapezius 
(figures  344,  345).  Part  of  the  scapula  and  clavicular  fibers  are 
dissected  up,  the  separated  muscle  is  raised,  a  towel  placed  above 
and  another  below,  while  three  sets  of  silk  sutures  are  quilted  into  it. 
The  superficial  fibers  of  the  pectoral  and  trapezius  muscle  are  scarified. 


194 


TECHNIQUE  OF  OPERATIONS 


A  broad  tunnel  is  made  below  the  subcutaneous  fat  connecting  the 
shoulder  and  pectoral  incisions  subcutaneously  (figure  346).  The 
pectoral  and  trapezius  muscles  are  introduced  and  retracted  allowing 
the  muscles  to  be  sutured  together  (figure  347).  The  muscles 
may  be  slit  into  three  portions  so  that  in-  overlapping,  two  tails  of 
one  muscle  will  go  forward  and  one  posterior  while  two  tails  of  the  other 

muscle  will  go  posteriorly  and  one 
forward  (figure  348).  The  muscles 
are  sutured  together  and  the  quilted 
silk  sutures  already  placed  are  ex- 


Fig.  346. — Intermediate  silk  and  sub- 
cutaneous tissue  raised  allowing  the  trape- 
zius and  pectoralis  to  be  approximated. 


Fig.  347. — Another  method  of  attaching  the 
trapezius  to  the  pectoralis;  scarification  and 
interrupted  sutures. 


Fig.  348. — The  split  trape- 
zius receives  the  pectoralis 
muscle  and  is  fastened  to  it 
by  quilted  sutures. 


AlM^ 


Fig.  349. — Both  incisions  are  closed  with  inter- 
rupted or  continuous  sutures. 


tended  from  one  muscle  to  the  other  and  quilted  in  such  a  way  that 
the  silk  coming  from  the  pectoral  is  quilted  into  the  trapezius.  Additional 
mattress  sutures  are  added  if  necessary.  The  muscle  circulation  must 
not  be  cut  off  by  too  many  sutures.  The  deep  tissues  are  brought 
together  with  interrupted  chromic  catgut  sutures  number  00,  the  sub- 
cutaneous fat  with  interrupted  chromic  catgut  sutures  number  00, 
the  skin  with  continuous  chromic  catgut  sutures.    A  plaster  of  Paris 


MUSCLE  AND  TENDON  OPERATIONS 


195 


dressing  is  applied  holding  the  arm  raised  above  the  head,  as  seen  in 
figures  316  and  317.  This  position  is  maintained  for  about  three  weeks, 
after  that  the  arm  is  gradually  brought  down  and  the  plaster  replaced 
by  a  wire  splint  (see  figures  314  and  315).  A  wire  shelf  (figure  314),  will 
replace  the  ordinary  plaster  at  the  end  of  two  months.  This  should 
be  used  for  nine  months  or  a  year,  holding  the  arm  in  sixty  degrees 
of  abduction,  the  elbow  not  being  allowed  to  drop  below  an  ab- 
ducted position  of  fifty  degrees.  The  hand  and  forearm  may  be  used 
on  the  shelf.  Stretching,  muscle  training  and  exercises  should  be  done 
daily  until  the  muscles  are  sufficiently  strong  and  serviceable. 

221.  Pectoralis  Major  Transplantation,  for  Paralysis  of  the  Deltoid. 
— Dr.  Legg  recommends  an  incision  one  inch  below  the  sternal  end  of 
the  clavicle  extending  outward  one  inch  below  the  clavicle  and  parallel 


Fig.  350. — Exposure  of  the  pectoralis  major.    The  sternal  end  dissected 
up  and  turned  back  to  cover  the  deltoid  and  the  shoulder. 

to  it  (see  figure  350).  The  incision  is  continued  along  the  anterior 
border  of  the  deltoid  almost  to  the  deltoid  tubercle. 

The  skin  and  superficial  fat  are  reflected  outward,  the  sternal  origin 
of  the  pectoralis  major  is  reflexed  outward  with  the  inner  two  thirds  of 
the  clavicular  origin,  avoiding  the  nerves  which  enter  just  below  the 
outer  third  of  the  clavicle.  The  lower  border  of  the  pectoral  is  freed 
from  its  insertion  (figure  351).  The  lower  sternal  origin  is  to  be  laid 
over  the  clavicle  and  extends  back  over  the  shoulder.  It  will  fill  well 
the  space  over  the  flattened  paralyzed  muscles. 

An  incision  is  now  made  along  the  spine  of  the  scapula  extending  from 
the  base  of  the  spine  outward  to  join  the  first  incision.  The  skin  and 
subcutaneous  fat  are  reflected  downward  and  upward  exposing  part  of 
the  trapezius.  The  dissected  origin  of  the  pectoralis  major  is  now 
turned  outward  so  that  it  lies  over  the  scapula,  the  sternal  portion 
of  its  origin  is  inserted  with  silk  into  the  periosteum  along  the  spine  of 
the  scapula.     The  clavicular  portion  and  the  upper  sternal  portion  is 


196  TECHNIQUE  OF  OPERATIONS 

inserted  into  the  substance  of  the  trapezius  muscle.  The  subcutaneous 
fat  is  brought  together  with  interrupted  chromic  catgut  number  00, 
the  skin  with  continuous  chromic  catgut  number  00.  The  arm  is  placed 
in  a  position  of  ninety  degrees  of  abduction  and  held  there  by  means  of 
a  plaster  of  Paris  bandage  or  a  wire  splint  made  for  the  purpose.    The 


Fig.  351. — Pectoralis  major  reflected  over  the  shoul- 
der and  attached  to  the  spine  of  the  scapula  to  become 
useful  in  raising  the  arm. 

after  treatment  is  the  same  as  that  described  under 
transplantation  of  the  trapezius  and  one-half  of  the 
pectoralis  major  insertion. 

222.  Operation  for  Paralysis  of  the  Biceps,  Trans- 
plantation of  the  Triceps. — The  patient  lies  on  his 
left  side  for  transplantation  on  the  right  arm  with  F 
large    pillows    or   sand    bags    to    steady   him.     The       0f  the  triceps, 
operator  stands  behind  the  arm  to  be  operated  on. 

An  incision  is  made  in  the  outer  third  of  the  posterior  aspect  of  the 
upper  arm,  extending  from  the  upper  and  middle  thirds  down  to  just 
below  the  external  condyle  (figure  352).  The  incision  is  carried  down 
to  the  muscle,  the  skin  and  fat  are  retracted  exposing  the  outer  edge  of 
the  triceps  and  its  tendon.  The  outer  third  of  the  tendon  is  detached 
below  the  elbow  and  dissected  upward  to  one  and  one-half  inches  above 
the  joint  (see  figures  353  and  354).  At  this  point  the  outer  half  of  the 
muscle  is  divided  and  its  muscle  fibers  separated  to  almost  the  junction 
of  the  upper  and  middle  thirds  of  the  arm.  A  second  incision  is  made 
anteriorly  in  the  middle  third  of  the  upper  arm  down  to  the  biceps. 
The  incision  is  then  carried  downward  to  the  bicipital  fascia  on  the  front 
of  the  forearm.  A  subcutaneous  tunnel  is  made  under  the  fat  connect- 
ing the  upper  ends  of  these  two  incisions,  a  tendon  carrier  or  clamp  is 
passed  from  the  anterior  incision  backward.  The  triceps  tendon  is 
grasped  and  drawn  forward  out  of  the  anterior  incision  (figure  354). 
Number  eighteen  braided  silk  is  quilted  up  one  side  of  the  tendon  and 
down  the  other  (figure  355).  At  this  point  one  of  four  methods  may  be 
adopted,  either  the  biceps  is  scarified  superficially,  the  triceps  also,  the 


MUSCLE  AND  TENDON  OPERATIONS 


197 


two  placed  in  apposition  and  sutured,  the  quilted  end  of  the  triceps  is 
inserted  and  fastened  to  the  bicipital  fascia  below  the  elbow;  or  second, 
the  biceps  may  be  lifted  on  a  blunt  dissector,  its  fibers  separated  longi- 
tudinally, the  triceps  passed  through  the  slit  and  its  end  carried  down  to 
the  bicipital  fascia  (figure  355)  where  it  is  sutured,  other  mattress  su- 
tures being  placed  to  hold  the  muscles  in  apposition ;  or  third,  the  triceps 
may  be  passed  through  a  slit  in  the  biceps  in  the  middle  of  the  upper  arm 
and  again  through  a  second  slit  lower  down  and  sutured  in  the  same  way; 


Fig.  353.— The  tri- 
ceps split  and  one 
half  to  be  trans- 
planted forward. 


Fig.  354.  — One 
half  of  the  triceps 
drawn  forward 
through  the  tunnel. 


Fig.  355.  — One 
half  of  the  triceps  C 
drawn  forward  and 
sutured  to  the  biceps 
D,  quilted  silk  exten- 
sion to  the  bicipital 
fascia  B. 


or  fourth,  the  biceps  may  be  cut  away  bodily  at  the  middle  of  the  upper 
arm  and  attached  to  the  triceps  by  interrupted  chromic  catgut  mattress 
sutures  wherever  necessary.  The  end  of  the  triceps  in  all  cases  should 
be  attached  below  the  bicipital  fascia,  by  means  of  silk  as  described 
above.  The  arm  is  put  up  in  a  plaster  of  Paris  bandage  or  a  posterior 
wire  splint  with  the  elbow  flexed  to  forty-five  degrees  more  than  right 
angle. 

Right  angle  flexion  should  be  maintained  at  least  nine  months,  allow- 
ing the  use  of  the  forearm  and  hand  and  allowing  motion  in  flexion  at  the 
elbow  but  not  extension  beyond  the  right  angle  position.  Muscle  train- 
ing and  exercises  should  be  done  daily  for  a  year  or  more,  depending  on 
the  case. 


CHAPTER  III 

OPERATIONS  IN  PARTIAL  AND  TOTAL  PARALYSIS 

223.  Flail  Conditions  of  the  Shoulder  and  Partial  or  Total  Disloca- 
tions of  the  Shoulder  Due  to  Paralysis. — In  paralysis  of  the  shoulder 
the  deltoid  ma}'  be  partially  or  completely  paralyzed.  See  also  Chap- 
ter II. 

When  a  flail  condition  has  existed  for  a  long  time,  especially  when  it 
has  existed  from  infancy,  there  is  often  a  dislocation  and  a  rounding 
down  of  the  acromion  process  over  the  shoulder.  When  a  transplanta- 
tion or  capsulorrhaphy  is  advisable  here,  it  is  sometimes  necessary  to 
do  an  osteotomy  of  the  acromion  to  allow  the  shoulder  to  be  relaxed. 
The  curved  acromion  will  often  interfere  with  the  normal  motion  of  the 
joint. 

224.  Operation  for  Depression  of  the  Acromion  over  the  Head  of 
the  Humerus  and  Capsulorrhaphy. — For  operation  on  the  right 
shoulder,  the  right  side  of  the  patient  is  elevated  by  sand  bags  or  hard 
cushions  under  the  right  thorax  from  the  angle  of  the  scapula  downward. 
The  shoulder  and  upper  three-fourths  of  the  scapula  are  held  well  off 
of  the  table.  The  cushions  should  be  placed  to  insure  a  firm  position  of 
the  patient  so  that  neither  he  nor  they  will  slide  during  the  operation 
and  manipulation  of  the  arm.  The  operator  stands  above  the  shoulder 
with  his  left  side  toward  the  head  of  the  patient  and  traces  the  curving 
acromion  with  his  left  hand. 

An  incision  is  made  down  to  the  bone  three-fourths  of  an  inch  long 
and  about  one  and  one-half  inches  from  the  tip  of  the  acromion.  An 
osteotome  is  used  to  cut  the  bone.  The  acromion  process  is  very  readily 
reached  and  cut,  through  an  extremely  small  incision.  A  second  incision 
is  made  over  the  anterior  aspect  of  the  humerus  about  one-half  inch  from 
the  anterior  border  of  the  deltoid  and  parallel  to  its  fibers.  See  figure  356. 
The  incision  is  carried  through  the  deltoid  fibers  separating  them  with  a 
blunt  instrument.  The  joint  capsule  is  readily  reached  and  reefed  by 
inserting  three  or  four  heavy  silk  quilted  sutures  (see  figure  333).  These 
are  tightened  and  tied  holding  the  head  of  the  humerus  close  to  the 
glenoid.  They  should  not  interfere  with  motion.  The  deep  tissues  are 
brought  together  with  interrupted  chromic  catgut  sutures  number  00 
and  the  subcutaneous  tissues  with  interrupted  chromic  catgut  sutures 
number  00,  the  skin  with  interrupted  horse  hair,  or  subcutaneous  or 
continuous  chromic  catgut  sutures  number  00.  The  shoulder  should 
be  held  abducted  to  right  angle  and  outwardly  rotated  about  sixty 
degrees  (see  figure  316).  A  plaster  dressing  is  applied  over  the  op- 
posite shoulder  and  the  chest  and  including  the  arm  and  hand,  allow- 

198 


OPERATIONS  IN  PARTIAL  AND  TOTAL  PARALYSIS        199 

ing  free  play  of  the  fingers  and  thumb.  A  wire  splint  is  sometimes 
used  instead  of  the  plaster  (see  figures  314  and  315).  The  arm  is  kept 
in  this  position  six  or  eight  weeks.  After  that  the  treatment  is  the  same 
as  that  described  under  transplantation  of  the  trapezius. 

225.  Arthrodesis  of  the  Shoulder  in  Paralytic  Conditions. — In 
paralytic  cases,  the  object  of  this  operation  is  to  take  advantage  of  the 
good  muscles  attached  to  the  scapula  and  use  them  to  control  and 
raise  the  shoulder.  This  is  accomplished  by  placing  the  arm  in  an 
abducted  position  and  fixing  it  to  the  scapula. 

For  operation  on  the  right  shoulder,  the  right  side  of  the  patient  is 
elevated  by  sand  bags  or  hard  cushions  under  the  right  thorax  from  the 
angle  of  the  scapula  downward.  The  shoulder  and  upper  three-fourths 
of  the  scapula  are  held  well  off  of  the  table.     The  cushions  should  be 


Fig.  356.— Retracted  del- 
toid exposing  the  joint  cap- 
sule. 


Fig.  357. — Tendon  of  the  biceps  displaced 
inward,  head  of  the  humerus  dislocated  ex- 
posing the  glenoid.  1,  Acromion.  2,  Cora- 
coid.  3,  Tendon  of  biceps,  behind  it  the 
glenoid. 


placed  to  insure  a  firm  position  of  the  patient  so  that  neither  he  nor 
they  will  slide  during  the  operation  and  manipulation  of  the  arm. 

An  anterior  incision  is  made  from  the  space  halfway  between  the  acro- 
mion and  coracoid  process  down  the  arm  parallel  to  the  bicipital  groove 
almost  as  far  down  as  the  insertion  of  the  deltoid.  The  incision  is 
carried  through  the  deltoid,  its  fibers  being  separated  with  a  blunt 
instrument  a  short  distance  from  its  inner  border,  the  muscle  fibers 
are  retracted,  the  bicipital  groove  is  located,  the  joint  capsule  opened 
here  (figure  356).  The  tendon  of  the  biceps  is  exposed  and  raised  from 
its  groove  and  displaced  inwardly  over  the  head  of  the  humerus.  This 
is  facilitated  by  rotation  of  the  arm.  The  capsule  is  elevated  and  dis- 
sected free  from  the  humerus  close  to  the  bone  (this  may  be  done  sub- 
periosteally  with  an  osteotome).  The  arm  is  manipulated  and  rotated 
to  aid  the  dissection,  allowing  the  capsule  to  be  dissected  from  the 
humerus  by  rotating  inward  and  outward.  The  head  is  displaced  well 
forward  allowing  free  access  to  the  glenoid  cavity  (see  figure  357). 


200  TECHNIQUE  OF  OPERATIONS 

Three  or  four  quilled  silk  sutures  are  placed  separately  into  the  freed 
capsule  so  that  both  ends  from  each  strand  quilted  in  are  firmly  attached 
to  the  capsule  and  used  to  hold  it  retracted  and  later  aid  in  finding  the 
edges  for  suture.  The  glenoid  surface  is  denuded  to  the  bone.  The 
surface  of  the  head  of  the  humerus  coming  in  contact  with  the  joint 
should  then  be  removed  so  that  the  head  of  the  humerus  and  denuded 
glenoid  will  be  in  smooth  flat  contact  assuring  a  complete  ankylosis 
between  the  scapula  and  the  head  of  the  humerus  with  the  arm  placed 
in  a  position  of  about  seventy  degrees  of  abduction.  These  bones  may 
be  drilled  and  fastened  together  with  heavy  silk  sutures.  Other  silk 
sutures  may  be  placed  through  the  acromion  and  the  tuberosity  of 
the  humerus.  The  arm  should  be  abducted  about  twenty  degrees 
more  than  the  final  position  desired.  When  the  silk  is  tied  the 
humerus  should  be  held  firmly  to  the  bone  in  the  desired  abducted 
position.  The  capsule  sutures  already  placed  are  brought  together  and 
tied,  holding  the  bone  firmly  in  place.  The  deep  tissues  are  brought 
together  with  interrupted  chromic  catgut  sutures  number  00,  the  sub- 
cutaneous fat  with  interrupted  chromic  catgut  sutures  number  00,  the 
skin  with  continuous  chromic  catgut  sutures  number  00. 

The  shoulder  is  held  firmly  in  this  position  by  a  well  fitting  plaster  of 
Paris  bandage  padded  throughout.  Extra  padding  is  placed  under  the 
elbow  over  the  shoulder  and  over  the  thorax  in  the  axillary  line. 
A  small  window  is  cut  for  inspection  of  the  incision  without  disturb- 
ing the  plaster.  The  arm  is  held  in  plaster  six  weeks.  The  patient 
is  kept  in  bed  for  two  weeks.  Motions  of  the  hand  and  wrist  are  en- 
couraged after  the  second  week.  After  the  sixth  week,  a  wire  shelf 
(see  figures  314  and  315)  is  used  bent  down  to  maintain  the  desired 
abduction,  about  seventy  degrees.  This  allows  the  use  of  the  arm,  fore- 
arm and  hand  and  abduction  of  the  shoulder  but  prevents  adduction. 
Exercises  and  muscle  training  should  be  used  in  connection  with  the 
splint  for  at  least  a  year.  After  that  the  splint  is  used  two  hours  a  clay, 
depending  on  the  strength  of  the  scapula  muscles.  The  object  of  the 
operation  is  to  take  advantage  of  the  scapula  to  raise  the  arm  when  the 
shoulder  muscles  are  paralyzed. 

226.  Bartow  Silk  Ligaments  at  the  Shoulder  in  Paralytic  Conditions. 
— At  the  shoulder  when  there  is  a  complete  paralysis  of  the  deltoid  and 
it  is  inadvisable  to  do  a  transplantation,  the  Bartow  silk  ligaments  may 
be  used  to  hold  the  shoulder  to  the  scapula.  They  will  also  hold  the 
head  of  the  humerus  close  to  the  acromion  and  allow  better  use  of  the 
muscles  when  there  is  a  partial  paralysis. 

OPERATION 

An  assistant  holds  the  humerus  close  to  the  acromion  in  a  neutral 
position  as  to  rotation,  the  elbow  being  flexed  at  right  angles;  the  fore- 
arm points  directly  forward.  The  Bartow  drill  described  above  is  in- 
serted through  the  acromion  from  above  downward  and  outward.    The 


OPERATIONS  IN  PARTIAL  AND  TOTAL  PARALYSIS        201 

drill  should  protrude  through  the  handle  a  very  little.  As  it  cuts  the 
bone  the  handle  is  placed  one-half  to  three-fourths  inches  further  back, 
keeping  the  handle  as  low  as  possible  on  the  drill.  The  drill  is  passed 
through  the  head  of  the  humerus  and  out  at  the  side.  As  it  protrudes 
through  the  skin  a  heavy  number  eighteen  silk  is  threaded  through  the 
eye  in  the  drill  and  drawn  through  the  skin  on  the  top  of  the  shoulder. 
The  drill  is  next  passed  downward  subcutaneously  through  the  joint 
capsule  if  possible  and  protrudes  through  the  opening  in  the  skin  below. 
The  silk  is  removed  from  the  drill,  the  drill  withdrawn,  leaving  both  ends 
of  silk  protruding  through  the  lower  hole  in  the  skin.  The  humerus  is 
placed  in  the  desired  position  close  to  the  acromion,  the  silk  is  tied  tightly 
three  times,  the  ends  cut  and  allowed  to  recede  through  the  hole  in  the 
skin  and  fat.  The  after  treatment  is  the  same  as  that  described  in  these 
pages  for  arthrodesis  of  the  shoulder.     See  section  225. 


CHAPTER  IV 

INCISION   PUNCTURE   AND   ARTHROTOMY 

227.  Arthrotomy. — A  knowledge  of  the  important  routes  of  approach 
to  the  joints  will  facilitate  any  joint  exploration,  the  removal  of  foreign 
bodies,  the  repair  of  traumatic  conditions,  the  adjustment  of  difficult 
fractures,  the  reduction  of  old  and  difficult  dislocations,  mobilization 
of  joints  where  motion  is  partially  or  totally  lost,  and  stiffening  the  joint 
as  in  certain  paralytic  conditions,  treatment  and  drainage  of  suppura- 
tive conditions;  a  knowledge  of  the  important  routes  of  approach  to 
the  joint  is  very  important.  For  each  case,  the  operator  will  select 
the  incision  best  suited  for  the  individual  condition.  Each  joint  will 
be  considered  separately  in  its  chapter. 

In  all  operations  on  the  joints,  the  incision  should  be  made  down  to 
the  synovial  membrane  and  made  large  enough  before  opening  the  syn- 
ovial cavity.  All  bleeding  should  be  stopped  and  the  synovial  mem- 
brane carefully  opened.  The  joint  structures  should  be  tampered  with 
as  little  as  possible,  the  synovial  membrane  brought  together  carefully 
and  the  layers  over  it  closed  in  order  not  to  disturb  the  function  of  the 
periarticular  tissues.  Unnecessary  separation  of  the  tissue  layers  is 
to  be  avoided.  Tendons  should  be  left  in  their  sheath.  Any  ligaments 
that  must  be  cut  should  be  loosened  subperiosteal^,  in  order  that  they 
may  be  readily  replaced.  Early  motion  should  be  the  rule,  gentle  at 
first,  and  gradually  increased. 

The  shoulder  joint  is  readily  opened  or  punctured  for  diagnostic 
purposes  but  joint  operations  should  never  be  hastily  considered  and 
should  be  avoided  by  anyone  not  familiar  with  the  best  surgical  tech- 
nique. 

Arthrotomy  of  the  shoulder  is  necessary  sometimes  for  bursitis,  some- 
times for  the  rupture  of  the  supra-spinatus,  sometimes  on  account  of 
disease,  sometimes  for  exploration,  in  cases  of  obscure  internal  derange- 
ment of  the  joint,  or  for  removal  of  a  foreign  body,  dislocation,  fracture, 
for  acute  infections  or  suppuration. 

Incision  in  the  overlying  tissues  should  be  made  to  one  side  of  the 
line  of  incision  in  the  capsule.  All  bleeding  should  be  stopped  before 
opening  the  synovial  cavity.  The  latter  should  be  opened  carefully 
and  the  cavity  itself  interfered  with  as  little  as  possible,  avoiding  rough 
and  sharp  instruments. 

For  reefing  the  capsule,  the  anterior  incision  is  often  the  best,  but  the 
posterior  may  be  used.  For  drainage,  the  operator  may  choose  the 
anterior  route  or  the  posterior,  or  both.  In  any  extensive  suppurative 
condition,  the  joints  should  be  thoroughly  drained.    At  times  an  anterior 

202 


INCISION,  PUNCTURE  AND  ARTHROTOMY 


203 


incision  with  a  puncture  posteriorly  will  give  sufficient  drainage.    This  is 
especially  so  in  the  case  of  suppurative  bone  conditions. 

228.  Anterior  Incision.  (See  Fig.  358.) — An  incision  is  made  from 
one-half  inch  below  the  acromion  downward  parallel  to  the  deltoid 
muscle  and  slightly  external  to  its  innermost  border.  The  incision  is 
made  three  or  four  inches  long.  A  layer  of  delicate  fat  is  reached  be- 
fore opening  the  joint  cavity.  The  sub-acromion  bursa  will  be  found 
under  the  deltoid  andacromion  (see  figure  358). 

When  more  room  is  necessary 

When  it  is  necessary  to  have  more  room  than  is  afforded  by  this  in- 
cision, it  is  extended  downward,  but  if  very  much  room  is  needed  it  is 
better  to  make  a  second  incision  joining  the  first  one-half  inch  below  the 
acromion,  extending  inward  one  inch  below  and  parallel  to  the  clavicle, 
separating  a  few  of  the  deltoid  fibers  (see  figure  359) .  This  extra  incision 
is  not  often  necessary  but  it 
is  very  useful  in  difficult  frac- 
tures and  dislocations.  The 
synovial  cavity  is  opened  in 
the  line  of  the  bicipital 
groove  which  is  easily  felt 
with  the  finger.  A  director 
is  placed  in  the  groove  and 
the  capsule  opened  on  it. 

If  it  is  necessary  to  have 
a  full  view  of  the  head  of  the 
humerus,  the  tendon  of  the 
biceps     is    lifted     from    its 
groove  with  a  blunt  dissector 
and  displaced  inward.     The 
shoulder   is  rotated  inward, 
then  outward  slowly  giving 
access  to  the  restricting  por- 
tions  of   the  capsule  which 
are  removed  subperiosteal^  parallel  to  the  del- 
to    allow    the    head    to    be  toidfibres- 
turned  out  through  the  incision  by  adducting  the  arm 
a  very  good  view  of  the  head  and  glenoid. 

The  anterior  route  is  a  simple  and  very  useful  route  of  approach  for 
operations  on  the  capsule,  for  excision,  arthrodesis,  and  certain  fractures. 

When  the  purpose  of  operation  is  accomplished,  the  head  is  replaced, 
the  biceps  tendon  placed  in  its  groove  and  the  overlying  tissues  sutured 
layer  by  layer  with  interrupted  chromic  catgut  sutures  number  00. 

229.  Posterior  Incision. — An  incision  is  made  starting  one-half 
inch  posterior  to  the  tip  of  the  acromion  downward  parallel  to  and  one- 
half  inch  from  the  posterior  border  of  the  deltoid  (figure  361).     The 


Fig.  358.  — An- 
terior incision  start- 
ing one  inch  below 
the  acromion  and 
extending  downward 


Fig.  359.  — An- 
terior incision  with 
extension  one  half  an 
inch  below  the  acro- 
mion extending  in- 
ward parallel  to  the 
clavicle. 

,    This  will  allow 


204 


TECHNIQUE  OF  OPERATIONS 


incision  is  carried  through  the  skin  and  fat  for  about  three  inches.  The 
deltoid  fibers  are  separated  with  a  blunt  instrument,  the  fat  overlying 
the  synovial  membrane  is  carefully  opened  and  finally  the  synovial 
membrane  is  lifted  with  forceps  and  incised. 

230.  Kocher  Incision. — This  incision  is  carried  from  the  acromio- 
clavicular joint  along  the  upper  border  of  the  acromion  and  the  spine 
of  the  scapula  to  its  root.  From  this  point,  the  middle  of  the  spine,  it 
is  curved  downward  and  forward  to  the  posterior  fold  of  the  axilla 
(figure  360).  The  acromio-clavicular  joint  is  cut  across  or  preferably  the 
fibers  of  the  acromion  legament  are  detached  subperiosteally  from  the 
acromion.  The  finger  or  a  blunt  dissector  separates  the  deltoid  from 
the  underlying  tissues.  The  muscles  are  separated  subperiosteally  from 
the  upper  and  lower  border  of  the  spine  of  the  scapula.    The  acromion  is 


J 


Fig.  360. — Kocher  incision  from 
the  acromio-clavicular  joint  back- 
ward to  the  root  of  the  spine  of  the 
scapula  and  then  downward  and 
outward  to  the  posterior  axillary- 
line. 

chiselled  through  and  is  re- 

,        ,    j     ~              j         • ,  i       ,i  Fig.  361. — Codman  incision  between  the  acromio- 

tracted     tor  ward    Wltn     tne  clavicular  joint   extending   forward,    separating   the 

deltoid.       The     Operator  deltoid  anteriorly  parallel  to  its  fibers  and  backward 

should  take  care  not  to  in-  Para^e^  to  the  posterior  margin  of  the  deltoid.    The 

.      '                          ,  posterior  portion  corresponds  to  the  posterior  incision. 

jure  the  supra-scapula  nerve 

which  passes  under  the  muscles  from  above  to  below  the  spine  into  the 
infra-spinatus  fossa.  A  hole  is  drilled  through  the  acromion  and  another 
through  the  spine  before  separating  the  latter  with  a  chisel.  Sutures  are 
placed  through  these  holes  before  separating  the  acromion  with  the  chisel. 
This  enables  them  to  be  replaced  easily  afterward,  the  head  of  the 
humerus  and  glenoid  fossa  are  fully  exposed,  after  lifting  the  bicipital 
tendon  from  the  groove  and  displacing  it  inward. 

231.  Codman  Incision. — The  saber  cut  Codman  incision  is  made 
over  the  acromio-clavicular  joint  extending  forward  and  backward 
along  the  anterior  and  posterior  border  of  the  deltoid  (figure  361).  The 
incision  is  continued  along  the  spine  of  the  scapula  to  its  root.  The 
acromion  is  separated  from  the  spine  by  means  of  an  osteotome  or  by  a 
gigli  saw.  The  acromion  is  first  detached  from  the  clavicle  anteriorly. 
It  is  displaced  forward  with  its  deltoid  attachment  exposing  the  glenoid 
and  the  humerus. 


INCISION,  PUNCTURE  AND  ARTHROTOMY 


205 


Fig.  362. — Burrell  incision.  The  arm 
is  abducted.  The  incision  separates  the 
pectoral  from  the  deltoid  extending  in- 
ward below  the  clavicle  one  or  two 
inches. 


This  incision  may  be  used  for  fractures  or  dislocations  or  for  explora- 
tion of  the  shoulder  joint. 

After  operation  the  shoulder  should  be  held  by  a  long  axillary  pad 
or  by  means  of  a  wire  or  plaster  splint  holding  the  arm  extended  straight 
above  the  head  or  abducted  ninety  degrees  and  outwardly  rotated 
forty-five  degrees  to  ninety  degrees,  depending  on  the  case.  Motion  in 
outward  rotation  is  very  easily  lost 
and  very  important  for  future  func- 
tion. 

During  convalescence  motion  in 
the  joint  is  encouraged  early  without 
changing  the  position  of  abduction 
and  outward  rotation  on  the  splint. 
When  small  arcs  of  motion  are  suc- 
cessfully obtained  without  much  dis- 
comfort more  motion  is  allowed.  Ex- 
ercises are  done  often  during  the  day 
but  a  very  little  at  a  time  at  first. 
After  ten  days  there  should  be  a 
marked  increase  in  the  ease  and  in  the 
arc  of  motion. 

232.  Fractures  of  the  Shoulder, — A  fracture  through  the  surgical 
or  anatomical  neck  or  head  or  tuberosity  with  or  without  dislocation  will 
very  frequently  require  treatment  by  the  open  method.  The  bone  is 
easily  reached  by  the  usual  shoulder  incisions.  As  these  fractures  are 
difficult  to  treat  no  attempt  at  reduction  should  be  made  until  a  careful 
diagnosis  is  obtained  from  an  x-ray.  There  is  no  necessity  for  haste. 
If  necessary,  the  operation  may  be  delayed  several  days  for  the  sake  of 
good  x-rays.  The  surgeon  having  assured  himself  of  the  exact  condition 
of  the  bone,  the  fracture  is  adjusted  and  plated  or  wired  or  bone  grafted 
as  the  case  requires.  See  sections  261,  262.  The  arm  should  be  held 
to  the  side,  the  forearm  pointing  forward,  with  a  large  or  small  trian- 
gular pad  in  the  axilla,  coaptation  splints,  a  shoulder  cap,  an  internal  an- 
gular elbow  splint,  a  body  swathe  holding  the  arm  to  the  side,  and 
the  patient  kept  in  bed  on  a  bed  rest,  the  elbow  unsupported  in  order  to 
allow  its  weight  to  act  on  the  lower  fragment  in  preventing  over-riding. 

When  the  fracture  has  healed,  if  the  original  trauma  has  been  great, 
it  may  be  necessary  to  abduct  and  outwardfy  rotate  the  shoulder  and 
hold  it  on  a  wire  splint  and  exercise  it  in  this  position  and  later  on  a  wire 
shelf  abducted  ninety  degrees.  The  shelf  is  gradually  lowered  as  the 
deltoid  and  other  shoulder  muscles  acquire  strength.  Motion  is  nec- 
essary after  the  third  or  fourth  week.  Long  immobilization  must  be 
avoided. 

233.  Fractures  About  the  Shoulder. — When  it  is  necessary  to 
operate  on  shoulder  fractures  they  are  usually  reached  through  a  simple 
anterior  incision  or  an  enlarged  anterior  incision.     For  posterior  frac- 


206  TECHNIQUE  OF  OPERATIONS 

tures  or  fracture  of  the  tuberosity  the  Kocher  incision  may  be  used. 
For  small  fractures  of  the  tuberosity  a  simple  posterior  incision  is  often 
sufficient. 

Fractures  of  the  surgical  neck  are  reached  by  an  anterior  incision, 
the  head  may  be  drilled  and  held  by  the  drill  during  the  adjustment  of 
the  fracture. 

In.  difficult  cases  both  an  anterior  and  a  posterior  incision  may  be 
necessary. 

A  most  complete  exposure  is  obtained  by  a  Kocher  incision  or  a 
Codman  incision. 

234.  Arthrotomy  for  Fractures  about  the  Shoulder  Joint. — The 
necessity  of  immediate  operation  in  fractures  about  the  joints  depends, 
as  in  other  fractures,  on  the  acuteness  of  the  local  and  general  reaction. 
When  these  do  not  contra  indicate  immediate  operation,  certain  frac- 
tures about  the  joints  may  require  treatment  by  the  open  method. 
Among  these  are  fractures  of  the  patella,  fractures  of  the  olecranon 
and  certain  fractures  of  the  surgical  neck  of  the  humerus,  fractures  and 
dislocations  combined  and  certain  fractures  of  the  neck  of  the  femur, 
all  compound  fractures,  even  when  the  protrusion  of  the  bone  has  been 
extremely  slight,  all  fractures  that  cannot  be  reduced  by  manipulation 
or  in  which  the  correction  cannot  be  maintained  or  where  apposition 
is  impossible,  many  fractures  combined  with  dislocation,  articular  frac- 
tures with  pieces  locking  or  limiting  the  joint  action. 

Where  there  is  a  great  deal  of  trauma  and  in  multiple  fractures  and 
in  cases  where  there  is  a  great  deal  of  shock  all  that  can  be  done  is  to 
immobilize  the  parts  until  a  favorable  time  for  operation.  In  selecting  a 
suitable  time  for  operation  when  it  is  found  necessary  to  operate  on  a 
fracture  if  there  is  no  immediate  contra  indication,  the  sooner  it  is  done 
the  better.  When  there  is  tremendous  swelling  one  should  always  wait. 
All  cases  should  be  operated  on  that  show  no  union  after  three  months 
of  good  treatment. 

Methods  of  treating  the  individual  fracture  cannot  be  considered  in  a 
limited  space  like  this.  The  writer  has  described  the  routes  of  approach 
to  the  different  joints  and  the  technique  of  these.  This  will  enable  the 
surgeon  from  his  knowledge  of  fractures  to  select  the  route  best  adapted 
for  the  individual  treatment  required  and  when  necessary  two  or  more 
incisions  may  be  used.  A  knowledge  of  the  technique  will  enable  the 
surgeon  to  work  rapidly  in  reaching  the  fracture  on  which  he  expects  to 
spend  time.     See  section  232. 

235.  A  Traction  Apparatus  for  Fractures  of  the  Shoulder  and  the 
Shaft  of  the  Humerus. — When  traction  is  of  advantage,  the  same 
apparatus  may  be  used  for  fractures  at  the  shoulder  and  for  fractures 
of  the  shaft  of  the  humerus  that  is  described  under  fracture  at  the  elbow. 
Section  262. 

236.  A  Method  of  Treating  Overlapping  Fractures. — Where  the 
bones  overlap,  an  excellent  method  of  treatment  is  one  suggested  to  the 


INCISION,  PUNCTURE  AND  ARTHROTOMY  207 

writer  many  3rears  ago  by  Dr.  Edward  Martin  of  Philadelphia.  In  the 
operation  when  the  surgeon  has  reached  the  fracture  the  ends  are  freed. 
A  tough  tape  or  webbing  is  used  ten  or  twelve  feet  long,  sterilized.  The 
two  ends  of  the  tape  are  tied  together,  a  loop  of  the  tape  is  placed  over 
the  distal  end  of  the  bone.  The  other  end  of  the  tape  is  thrown 
over  the  foot  of  the  operating  table,  a  thirty-five  pound  weight  is  at- 
tached to  this  by  an  assistant.  In  about  five  minutes  the  bones  will 
be  found  to  be  separated  at  least  one  inch.  The  weight  is  then  held  up 
by  a  non-sterile  assistant,  the  tape  taken  off  of  the  end  of  the  bone  and 
clamped  to  the  sheet  on  the  operating  table,  so  that  it  will  not  slip  away 
while  the  surgeon  works  on  the  fracture.  When  the  muscles  are  in  fairly 
good  tone  or  the  overlapping  of  bone  has  been  great,  it  will  be  found  that 
the  bones  will  overlap  again  in  four  or  five  minutes.  A  reapplication  of 
the  tape  will  separate  the  bones  again  for  the  same  length  of  time.  The 
end  of  the  lower  bone  should  not  be  cut  or  freshened  until  all  other 
procedures  are  done  which  require  separation  of  the  bone.  When  these 
have  all  been  done  the  end  of  the  bone  over  which  the  tape  has  been 
placed  is  freshened.  After  this  the  tape  should  not  be  placed  on  the 
end  of  the  bone,  unless  it  is  very  necessary  but  the  two  ends  allowed  to 
come  together  and  held  by  a  clamp  until  the  operation  is  complete. 

Very  bad  overlapping  fractures  have  been  treated  in  this  way  in  fresh 
cases  without  the  necessity  of  shortening  the  bone.  In  old  fractures  no 
more  bone  need  be  removed  than  is  required  by  the  conical  condition 
of  the  ends.     See  section  232. 

237.  Fractures  of  Long  Standing  Still  Ununited  or  United  with 
Deformity,  Preventing  Function. — In  fractures  of  long  standing  where 
there  is  a  mild  infection,  conservative  treatment  should  be  tried 
first.  When  this  has  been  tried  free  drainage  should  be  established  and 
at  the  same  time  the  ends  of  the  bone  freshened  up  slightly.  Unless  the 
infection  is  marked,  in  many  of  these  cases  when  the  suppuration  dis- 
appears, union  has  also  taken  place.  In  any  case  where  there  has  been  in- 
fection, no  plastic  operation  should  be  used  until  the  infection  has  been 
entirely  absent  for  at  least  nine  months,  a  year  is  safer.  Where  the  infec- 
tion is  very  mild  and  of  long  standing,  during  the  process  of  treatment  the 
patient  may  be  allowed  to  walk  on  the  other  leg  if  the  local  reaction  is 
not  too  great.  Sometimes  he  may  walk  a  little  on  the  affected  leg.  It  is 
of  advantage  in  certain  cases  to  use  a  Thomas  splint  to  take  some  of  the 
weight  off  of  the  affected  leg,  the  patient  being  allowed  to  bear  weight 
on  the  ball  of  the  foot,  the  splint  taking  all  the  weight  off  of  the  heel. 
Where  the  x-ray  shows  conical  ends  of  the  bone  it  is  practically  useless 
to  expect  union  without  surgical  interference. 

238.  Tapping  the  Shoulder  Joint. — The  most  scrupulous  aseptic 
precautions  are  necessary  both  as  to  the  preparation  and  the  protection 
of  the  field  of  the  operation. 

It  is  rarely  necessary  to  tap  the  shoulder  joint.  When  there  is  much 
swelling,  the  synovial  cavity  is  more  readily  reached.     It  is  tapped  ex- 


208  TECHNIQUE  OF  OPERATIONS 

ternaJly  just  anterior  to  the  acromion  halfway  between  it  and  the  most 
anterior  portion  of  the  deltoid,  obliquely  down  and  back.  The  sub- 
deltoid and  subacromial  bursa  must  not  be  forgotten.  The  tapping 
may  be  done  with  ethyl  chlorid  or  novocaine  adreneline  solution,  1%. 

When  there  is  much  effusion  it  is  not  difficult  to  reach  the  joint.  The 
skin  is  drawn  to.  the  side  so  that  the  hole  in  the  skin  and  muscle  will  be 
out  of  line  when  the  needle  is  removed.  If  fluid  is  to  be  drawn,  and  other 
solutions  are  to  replace  it,  the  amounts  should  be  carefully  measured. 
Two  good  graduated  metal  S}Tinges  are  very  useful.  All  of  their  parts 
should  be  tested  beforehand.  The  trocar  is  made  to  enter  the  joint  and 
then  is  connected  with  the  syringe.  As  little  air  as  possible  should 
enter  the  joint.  The  trocar  should  be  of  large  diameter  as  the  fluid 
may  be  thick  or  flaky.  When  the  patient  is  not  anaesthetized  for  the 
operation  it  is  often  well  to  have  a  short  flexible  tube  connect  the  trocar 
with  the  syringe.  This  should  be  fastened  at  both  ends  by  silk  ties  so 
that  it  will  not  leak  easily  when  pressure  or  suction  is  used.  If  the 
joint  is  to  be  washed  out  a  definite  amount  of  fluid  is  injected  and  the 
return  measured  in  a  sterilized  measuring  glass. 

Dr.  Murphy  uses  a  formalin  glycerine  solution  as  follows: — Liquor 
formaldehyde  2%  in  glycerine,  about  ten  drops  of  the  formaldehyde 
to  each  ounce  of  glycerine. 

This  acts  very  well  in  infectious  synovitis.  But  it  should  not  be 
used  in  arthritis  deformans  nor  in  old  chronic  arthritis. 

The  tapping  may  be  done  with  ethyl  chlorid  or  novocaine  adreneline 
solution,  1%.  The  solution  should  be  prepared  twenty-four  hours  before 
it  is  used  (Murphy). 


CHAPTER  V 

OPERATIVE   TREATMENT   IN   CASES    OF  JOINT  ANKYLOSIS 

239.  Partial  Excision  of  the  Shoulder  for  Ankylosis. — When  there 
is  ankylosis  of  the  shoulder,  a  partial  excision  may  be  done.  The  opera- 
tion is  the  same  as  that  described  here  under  Excision,  with  this  excep- 
tion:— that  only  enough  of  the  bone  is  removed  to  allow  free  motion. 
The  attachment  of  the  infra  spinatus  and  the  deltoid  should  be  carefully 
replaced  and  the  arm  held  abducted  ninety  degrees  and  outwardly 
rotated  ninety  degrees.  This  position  is  maintained  until  the  tone  of 
the  muscles  is  partly  recovered  by  exercising  in  this  position. 

240.  Excision  of  the  Shoulder  to  Relieve  Ankylosis. — When  the 
shoulder  is  ankylosed  an  arthroplasty  is  the  operation  of  choice.  When 
there  has  been  no  disease  for  at  least  a  year  and  if  the  condition  was  not 
originally  tubercular,  a  partial  incision  may  be  done,  allowing  a  loose 
joint  with  motion. 

The  operation  is  performed  as  described  for  excision,  the  head  is  re- 
moved, the  sharp  bony  edges  are  removed  and  the  arm  placed  in  a  posi- 
tion of  ninety  degrees  outward  rotation  and  ninety  degrees  of  abduc- 
tion in  plaster.  In  three  weeks  a  wire  splint  is  used  and  exercise  and 
motion  are  encouraged  on  this  wire  shelf  splint  for  four  months.  The 
arm  is  held  there  in  a  position  of  ninety  degrees  of  abduction  and  in  a 
neutral  position  as  to  rotation  until  the  shoulder  muscles  have  acquired 
strength. 

241.  Arthroplasty  for  Ankylosis  of  the  Shoulder. — Ankylosis  may 
be  bony,  cartilaginous  or  fibrinous,  it  may  be  periarticular,  ligamentous 
and  capsular,  or  extra  articular,  that  is,  skin  scars,  tendons,  fascia,  nerves 
and  arteries. 

The  form  of  ankylosis  that  exists  will  determine  the  treatment. 
A  partial  ankylosis  at  certain  joints  had  better  not  be  treated  by  an 
arthroplasty. 

Age  must  be  considered,  also  the  general  condition  of  the  patient. 
When  the  ankylosis  is  bony,  cartilaginous  or  fibrinous,  arthroplasty  is 
indicated.  When  the  condition  is  periarticular  or  extra  articular,  it 
may  be  treated  by  capsulotomy,  tendon  elongation,  excision  of  exostoses, 
etc. 

Dr.  Murphy  lays  stress  on  the  following  points: — The  principles  of 
asepsis  to  the  finest  detail  are  absolutely  essential.  One  not  familiar 
with  the  best  surgical  technique  should  avoid  arthroplastic  operations. 
The  exposure  of  the  joint  must  be  generous  and  careful.  The  excision 
of  the  ankylosis  must  be  complete.  The  contracted  capsular  ligaments 
and  soft  parts  must  be  freed  and  if  necessary  lengthened.     The  normal 

209 


210  TECHNIQUE  OF  OPERATIONS 

contour  of  the  joint  should  be  restored  as  nearly  as  possible.  The  operator 
should  obtain  a  hyper-mobilization  of  the  joint.  The  joint  should  be 
re-shaped  to  give  stability.  The  inter-position  of  material  to  prevent 
reunion  of  the  bone  is  necessary.  The  principle  is  to  separate  the  bones 
and  to  interpose  between  them  material  to  prevent  bony  union.  The 
best  material  for  this  purpose  is  a  pedicle  flap  composed  of  fat,  muscle, 
fascia,  or  a  combination  of  these. 

When  this  is  not  possible,  a  transplantation  is  made  of  fat  and  fascia 
from  the  trochanter  bursa  region  or  from  the  fascia  lata. 

Materials  such  as  ivory,  celluloid,  silver  are  not  especially  good. 
Materials  that  will  not  absorb  or  that  absorb  too  slowly  are  not  desir- 
able. 

During  the  operation  the  soft  parts  should  be  freely  liberated.  At- 
tach the  interposing  flap  to  one  bone  only  and  cover  it  completely. 
Early  motion,  that  is,  active  or  passive,  at  the  end  of  five  to  seven  days 
is  necessary  with  or  without  gas  or  gas  oxygen. 

Dr.  Murphy  records  failures  in  arthroplasty  as  due  to  first,  insufficient 
and  defective  exsection  of  the  capsule  and  ligaments,  second,  insufficient 
interposition  of  fat  and  fascia  between  the  separated  bony  surfaces, 
third,  infection,  fourth,  the  sensitiveness  of  pain  on  motion  after  opera- 
tion. 

Cases  of  primary  tuberculosis  and  cases  of  recent  infection  that  have 
subsided  are  not  suitable  cases  for  arthroplasty.  In  operation,  in  addi- 
tion to  the  usual  protection  of  the  field  of  operation,  after  the  skin  and 
fat  have  been  incised,  towels  should  be  clamped  to  the  edges  of  the  skin 
as  an  extra  protection. 

The  patient  lies  on  his  back  with  a  hard  pillow  or  sand  bag  under  the 
middle  of  the  back  and  scapular  to  hold  the  shoulder  off  of  the  operating 
table.  The  operator  stands  on  the  side  of  the  shoulder  to  be  operated 
on. 

Dr.  Murphy  uses  an  incision  starting  one-half  inch  below  the  acro- 
mion downward  parallel  to  the  fibers  of  the  deltoid  and  one-half  inch 
from  its  internal  margin.  The  incision  extends  four  inches  downward 
through  the  skin  and  fat  to  the  muscle.  A  transverse  incision  is  made 
at  right  angles  across  the  chest  over  the  middle  of  the  pectoralis  major. 
The  fibers  of  the  deltoid  are  separated  with  a  blunt  dissector,  the  shoul- 
der is  rotated  so  that  the  bicipital  groove  comes  in  the  line  of  incision. 
The  blunt  dissector  is  slid  under  the  capsule  in  this  groove.  The  cap- 
sule is  cut  on  the  director  up  to  the  acromion.  The  capsule  is  removed 
subperiosteal^  from  the  humerus  as  far  as  possible  anteriorly  and  in- 
ward and  outwardly  and  backward.  Long  silk  sutures  may  be  placed 
in  the  capsule  to  hold  it  retracted  so  that  it  may  easily  be  recognized 
later  on.  The  tendon  of  the  biceps  is  lifted  on  a  blunt  dissector  and 
displaced  inward.  The  head  of  the  humerus  is  separated  from  the 
glenoid  with  a  curbed  chisel  and  rounded,  following  the  original  ana- 
tomical lines  as  nearly  as  possible.     A  flap  of  fat,  aponeurosis  and  muscle 


OPERATIVE  TREATMENT  IN  JOINT  ANKYLOSIS  211 

is  taken  from  the  middle  of  the  pectoralis  major.  Dr.  Murphy  advises 
a  flap  four  and  one-half  inches  by  three  and  one-half  inches  out  of  the 
middle  of  the  pectoralis  major.  The  pedicle  is  left  attached  to  the 
humerus  and  should  be  large  enough  to  completely  cover  the  bony 
surface.  The  head  of  the  humerus  is  placed  against  the  glenoid  which 
has  been  smoothed.  Over  the  head  is  stretched  the  fat,  aponeurosis 
and  muscle  flap.  These  have  been  firmly  sutured  so  that  they  will  re- 
main around  the  head.  The  capsule  is  now  fastened  to  the  humerus 
with  interrupted  chromic  catgut  sutures  number  00,  the  muscles  are 
attached  with  interrupted  chromic  catgut  sutures  number  00,  the  fat 
brought  together  with  interrupted  chromic  catgut  sutures,  the  skin 
with  continuous  chromic  catgut  sutures. 

The  under  surface  of  the  pectoralis  major  muscle  is  freed  with  a  blunt 
dissector  so  that  its  fibers  can  be  brought  together  wherever  there  is  a 
gap  in  the  tendon  or  muscle.  The  skin  and  fat  are  brought  together 
with  interrupted  chromic  catgut  sutures.  If  the  surgeon  prefers  to 
use  the  deltoid  instead  of  the  pectoral,  an  incision  is  made  four  inches 
long  below  the  clavicle  passing  external  to  the  deltoid  fibers,  between 
the  deltoid  and  pectoral.  This  will,  expose  the  joint  completely  if  the 
directions  are  followed  as  above.  After  freeing  and  shaping  the  bone, 
the  deltoid  is  cut  transversely  and  a  piece  interposed  four  inches  wide 
between  the  head  and  the  glenoid. 

It  has  been  suggested  by  Dr.  Coville  to  remove  a  piece  from  the  sur- 
gical neck  and  give  motion  at  this  point  by  interposition  of  the  deltoid. 
This  he  reports  as  a  practical  operation. 

After  arthroplasty  of  the  shoulder  the  weight  of  the  arm  should  be 
lifted  from  the  shoulder  by  a  wire  splint  holding  the  arm  in  an  abducted 
and  outwardly  rotated  position  (see  figures  311,  312).  Motion  is 
begun  with  the  arm  still  on  the  splint  at  the  end  of  a  week  or  ten  days. 
"When  motion  is  possible  without  pain  or  discomfort  it  is  increased  and 
the  splint  lowered  as  soon  as  the  shoulder  is  strong  enough,  which  will 
not  be  before  the  fourth  to  the  sixth  week. 


CHAPTER  VI 

OPERATION   IN   SUPPURATIVE    CONDITIONS 

242.  Osteomyelitis. — In  osteomyelitis  an  operation  should  be  done 
as  early  as  possible  after  making  the  diagnosis.  In  sub-acute  cases, 
incision  and  drainage  are  all  that  is  necessary.  Whenever  incising  for 
abscess  all  the  pockets  should  be  opened  and  if  the  abscess  is  large,  coun- 
ter incisions  are  made  at  dependent  portions.  The  pus  pocket  should 
be  opened  freely,  wiped  out  with  gauze,  irrigated  and  wiped  out  again 
with  gauze.  Curetting  should  be  avoided  excepting  for  the  removal 
of  sinuses  in  the  skin  and  in  cases  of  sinuses  it  is  often  better  to  excise 
them.  Perforated  rubber  tubing  should  be  placed  to  drain  the  deepest 
portions  of  the  pockets.  The  skin,  fat  and  superficial  muscle  layers 
should  be  made  to  gap  by  means  of  gauze  drains.  At  the  end  of  ten 
days  the  gauze  is  removed  and  the  tubes  shortened.  The  tubes  are 
gradually  drawn  out  a  little  each  day  or  two  until  not  used.  This 
method  makes  the  repeated  reapplication  of  drains  and  wicks  unneces- 
sary as  the  wound  will  gap  of  itself  and  close  from  the  bottom  if  the 
surgeon  has  been  careful  to  make  large  incisions. 

Where  the  periosteum  is  found  destroj^ed  or  the  pus  under  the  perios- 
teal layer,  the  bone  should  be  opened  by  means  of  a  large  drill  or  a  small 
gouge.  Where  this  is  necessary,  the  incisions  should  be  large  and  the 
counter  incision  should  be  made  on  the  other  side  of  the  bone  with  a 
hole  made  in  the  bone  a  little  above  or  below  the  hole  on  the  opposite 
side  (figure  66).  These  holes  in  the  bone  should  open  up  the  medullary 
cavity.  They  should  alternate  on  one  side  and  the  other  as  far  up  and 
down  as  the  disease  is  suspected.  When  the  abscess  is  very  great  and 
the  bone  involvement  is  large  a  number  of  good  sized  holes  should  be 
made  with  a  Burr  drill  or  a  curved  gouge  on  both  sides  of  the  bone  as 
shown  in  figure  67.  The  wound  should  be  gaped  widely; — the  skin, 
fat  and  superficial  muscle  held  open  by  large  gauze  drains.  The  tubes 
should  reach  from  the  surface  to  the  deepest  portions  of  the  abscess 
cavity.  Splints  should  always  be  applied  to  immobilize  the  limb. 
They  should  be  placed  so  that  they  will  not  interfere  with  the  dress- 
ing. In  some  instances  it  is  better  to  apply  plaster  with  large 
windows  and  ropes  to  give  stability  as  shown  in  figures  459-460.  The 
dressing  should  be  done  every  day  or  twice  a  day,  depending  on  the  foul 
condition  of  the  discharge.  If  the  odor  is  excessive,  chlorinated  soda 
dressing  should  be  used  diluted,  using  it  V2,  llz,  or  1/i  the  U.  S.  P.  strength. 
The  gauze  drains  should  be  left  for  at  least  ten  days  without  being  dis- 
turbed.   When  removed,  granulations  will  be  formed  under  them  in  such 

212 


OPERATION  IN  SUPPURATIVE  CONDITIONS  213 

a  way  as  to  keep  the  wound  open  without  applying  the  drains.  Irriga- 
tion may  be  used  at  the  time  of  operation  and  the  wound  thoroughly 
wiped  out  with  gauze  afterward.  No  irrigation  or  probing  or  application 
of  wicks  will  be  necessary  if  the  first  drain  is  left  in  long  enough.  After 
the  first  ten  days  the  tubes  are  shortened  up  gradually  until  they  are  not 
needed.     See  Carrell-Dakin  technique,  section  323. 

In  severe  cases  where  the  patient  is  unconscious  or  delirious,  the  bone 
should  always  be  opened,  three  or  four  holes  on  either  side  made  with  a 
gauge  or  good  sized  Burr  drill.  In  no  case  should  the  incision  be  made 
only  on  one  side  of  the  leg  in  severe  cases.  No  tight  packing  should  be 
used  as  this  interferes  with  good  drainage.  Where  sequestra  have 
formed  they  should  be  removed.  An  x-ray  should  be  taken  whenever 
possible  to  determine  the  position  of  the  disease  (unless  the  case  is  ur- 
gent and  an  immediate  x-ray  is  not  obtainable). 

In  cases  of  long  standing  that  are  sub-acute  at  the  first  examination, 
where  the  bone  is  riddled  with  holes  over  an  extremely  long  area,  it  is 
impossible  often  to  remove  the  dead  bone  satisfactorily  without  re- 
moving all  the  bone.  In  these  cases  free  incision  down  to  the  bone  with 
frequent  openings  into  the  bone  as  described  above,  will  allow  the  septic 
process  to  run  its  course  and  the  sequestra  to  gradually  separate.  We 
have  had  some  cases  in  which  the  lower  third  of  both  femora  were  riddled 
with  holes  and  full  of  sequestra,  the  patient  being  in  no  condition  for 
extensive  operation,  and  yet  not  very  ill.  In  these  cases,  however,  if 
the  surgeon  had  seen  the  patient  in  time  an  early  operation  would  have 
prevented  this  extreme  condition. 

Sometimes  it  is  necessary  to  close  a  large  bone  cavity  which  will  not 
heal  over.  Where  the  process  is  distinctly  septic  no  plastic  operation 
should  be  done  without  first  doing  an  operation  to  eliminate  the  septic 
condition.  After  that,  part  of  the  muscle  may  often  be  transferred  over 
such  a  cavity  after  it  is  closed.  In  transferring  a  muscle  over  such  a 
cavity  it  should  be  freely  transplanted  and  held  there  without  tension. 
The  skin  should  be  brought  together  over  the  muscle  and  the  wound 
drained,  as  there  is  apt  to  be  inflammatory  disturbance. 

Where  sequestra  are  present  it  is  always  desirable  to  remove  them  as 
soon  as  they  have  separated  and  the  involucrum  is  strong  enough  to  act 
as  a  support.  Sequestra  may  be  superficial  or  in  the  medullary  cavity 
or  both.  Where  there  is  a  persistent  sinus  and  a  sequestrum  is  present, 
pus  will  continue  to  form  until  the  sequestrum  is  removed.  Cases  dis- 
charging several  years  where  sequestrum  is  present  may  close  in  a  few 
weeks  after  removal  of  the  sequestrum. 

In  closing  a  bone  cavity  its  edges  may  be  chiselled  clean  and  then  the 
bone  incised  a  short  distance  from  one  edge  and  parallel  to  it,  the  incision 
is  carried  down  to  the  medulla,  the  incision  in  the  bone  is  widened  by 
prying  it  open  and  forcing  the  bone  together,  closing  the  old  cavity. 
This  is  sometimes  a  satisfactory  method  of  closing  an  old  open  bone 
cavity  which  has  schlerosed  edges. 


214  TECHNIQUE  OF  OPERATIONS 

243.  Suppurative  Conditions  of  the  Shoulder. — In  suppurative 
conditions  about  the  shoulder  joint  an  anterior  incision  through  the 
deltoid  fibers  is  a  convenient  route  of  approach.  This  will  usually  have 
to  be  supplemented  by  a  posterior  opening  and  sometimes  by  one  in  the 
axilla. 

The  joint  is  then  washed  out  thoroughly  before  replacing  the  head, 
the  abscess  cavhyr  is  well  wiped  out  with  gauze  and  drains  applied.  The 
angles  of  the  wound  are  held  apart  by  rolls  of  gauze  and  tubes  are  placed 
to  the  depth  of  the  suppurating  cavities.  If  the  disease  is  extensive  or 
there  is  to  be  prolonged  drainage  or  in  cases  where  disease  is  extremely 
virulent,  the  operator  should  use  large  anterior  and  posterior  incisions, 
keeping  them  well  open  with  sponges  in  addition  to  the  tubes  inserted 
to  the  deep  pockets. 

Where  there  is  extreme  suppuration,  a  wire  splint  is  preferable  to  a 
plaster  unless  the  latter  is  applied  with  large  windows  and  ropes  as  shown 
in  figures  459,  460.      See  the  Carrell-Dakin  technique,  section  323. 

244.  Excision  of  the  Shoulder  in  Suppurative  Conditions. — An  ex- 
cision of  the  shoulder  may  be  indicated  in  certain  cases  of  tuberculosis 
of  the  joint,  in  cases  of  extensive  suppuration,  for  certain  compound 
fractures,  for  irreducible  dislocations  sometimes,  for  ankylosis,  etc. 

The  patient  lies  on  his  back,  a  sand  bag  or  hard  pillow  is  placed  under 
the  middle  of  the  back  to  raise  the  shoulder  well  off  of  the  operating 
table.  The  operator  stands  on  the  same  side  of  the  patient  as  the  arm 
to  be  operated  on;  the  field  is  protected  in  such  a  way  that  the  arm  and 
hand  protected  in  a  sterile  sheet,  may  be  manipulated  into  any  position. 

OPERATION 

An  incision  is  made  one-half  inch  below  the  acromion  extending  down- 
ward parallel  to  the  fibers  of  the  deltoid  and  one-half  inch  to  the  outer 
side  of  its  anterior  inner  margin.  The  incision  is  carried  down  four 
inches  through  the  skin  and  fat  to  the  muscle.  The  muscle  fibers  are 
next  separated  with  a  blunt  instrument  for  the  whole  length  of  the 
incision.  When  the  deltoid  is  retracted  the  operator  will  easily  detect 
the  bicipital  groove  with  his  finger  and  make  an  incision  down  to  it 
by  passing  a  director  in  the  groove  and  cutting  the  capsule  on  the  director 
up  to  the  acromion. 

If  the  excision  is  done  to  obtain  ankylosis  as  in  paralytic  conditions  or 
to  obtain  motion  in  cases  of  ankylosis  either  from  injury,  old  disease,  or 
fracture,  the  operator  will  not  need  to  remove  much  bone.  When,  how- 
ever, a  great  deal  of  bone  must  be  removed  on  account  of  extensive  dis- 
ease, it  will  be  necessary  to  detach  some  of  the  important  muscles.  The 
tendon  of  the  biceps  will  be  lifted  from  its  groove  on  a  blunt  dissector 
and  displaced  inward,  while  the  shoulder  is  rotated  slowly  inward  and 
then  outward  during  the  process  of  freeing  the  capsule  subperiosteal^ 
and  also  the  attachment  of  the  supra  and  infra  spinatus  and  teres 
minor  from  the  great  tuberosity.     The  sub-scapularis  teres  major  ex- 


OPERATION  IN  SUPPURATIVE  CONDITIONS  215 

tend  to  the  lesser  tuberosity.     This  relieves  at  the  same  time  the  cor- 
raco-humeral  ligament. 

The  head  is  now  easily  brought  out  of  the  wound  and  the  necessary 
bone  sawed  off  below  the  cartilage  line.  The  axillary  nerve  and  circum- 
flex artery  must  be  remembered.  With  care  they  will  not  come  into 
view.  In  children  the  epiphyseal  line  should  be  preserved.  After  re- 
moving the  necessary  amount  of  bone,  rongeurs  are  used  to  remove  the 
sharp  edges  of  the  bone.  The  glenoid  cavity  is  inspected  and  any  dis- 
eased portion  removed  with  a  chisel,  not  with  a  curette. 

Unless  the  disease  is  extremely  slight,  posterior  drainage  should  be 
secured  by  a  posterior  opening.  A  pair  of  forceps  is  pushed  through 
the  tissues  and  made  to  protrude  posteriorly.  As  they  protrude,  a  one 
and  one-half  inch  incision  is  made.  If,  however,  the  operation  is  done 
to  obtain  ankylosis,  or  to  give  motion,  no  drainage  is  necessary  and  the 
incision  is  closed  completely. 

The  capsule  which  was  detached  is  brought  down  to  the  humerus  and 
sutured  anteriorly  and  posteriorly  with  kangaroo  or  chromic  catgut 
sutures  number  one,  the  muscles  with  chromic  catgut  sutures  number 
00,  the  fat  also;  the  skin  with  continuous  chromic  catgut  sutures  number 
00. 

When  drainage  is  necessary,  the  edges  of  the  wound  and  the  pos- 
terior incision  are  gaped  by  means  of  round  wads  of  gauze,  extending 
through  the  skin,  fat  and  superficial  muscle,  tube  drains  are  placed 
between  and  extend  to  the  deepest  portions  of  the  wound.  The  arm 
should  be  held  in  an  abducted  position  of  not  less  than  forty-five  degrees, 
a  large  pad  being  placed  under  the  elbow  so  that  it  may  be  held 
strapped  up  to  allow  good  healing  of  the  approximate  soft  tissues. 

When  the  operation  is  done  to  obtain  motion,  the  shoulder  is  held 
abducted  ninety  degrees  and  outwardly  rotated  sixty  degrees  on  a  wire 
splint  or  in  plaster  (see  figures  314  to  317). 

When  the  operation  is  done  to  obtain  ankylosis  as  in  certain  paralytic 
conditions  in  order  that  the  scapula  muscles  may  be  used  to  control  the 
actions  of  the  humerus,  the  arm  is  abducted  about  seventy  degrees 
and  held  firmly  (see  Arthrodesis  of  the  Shoulder). 

245.  Excision  of  the  Scapula  in  Suppurative  Conditions. — The 
patient  lies  on  the  opposite  side  of  the  body  in  a  semi-prone  position. 

An  incision  is  made  over  the  posterior  inner  border  of  the  scapula. 
This  is  joined  by  a  second  incision  extending  along  the  spine  of  the  scap- 
ula to  the  tip  of  the  acromion.  An  osteotome  is  used  to  remove  the 
muscles  subperiosteally  from  the  inner  border  of  the  scapula  extending 
upward  along  the  upper  border.  The  operator  will  next  work  from  the 
inferior  angle  upward  along  the  axillary  border  and  the  under  side  of 
the  scapula.  An  osteotome  is  used  to  remove  subperiosteally  the  trape- 
zius, the  supra  and  infra  spinatus  muscles  working  from  within,  outward. 
The  acromion  is  chiselled  through  with  an  osteotome,  freeing  it  from  the 
spine  of  the  scapula,  the  corracoid  is  freed  at  its  base  with  an  osteotome. 


216  TECHNIQUE  OF  OPERATIONS 

The  supra  scapular  nerve  should  be  avoided.  Several  small  arteries  will 
have  to  be  ligated.  When  the  inner  and  outer  portions  of  the  scapula 
are  cleared  from  below  upward,  the  scapula  is  lifted  by  its  lower  angle 
so  that  the  anterior  surfaces  may  be  cleared  of  the  sub-scapular  muscle 
and  serratus.  All  that  remains  after  this  are  the  attachments  of  the 
capsule  and  omohyoid  muscle.  The  circumflex  artery  and  transverse 
arteiy  of  the  scapula  may  give  some  bleeding.  The  supra  scapular  nerve 
accompanies  the  transverse  scapular  artery.  When  possible  the  joint 
should  be  left. 

The  shock  from  this  operation  is  very  much  less  than  that  of  removing 
the  arm  and  blade.  W7henever  this  limited  operation  may  be  done  it 
is  preferable  for  this  reason  to  a  complete  removal  of  the  arm  and  scapula. 
After  removal  of  the  scapula  the  joint  may  be  attached  to  the  clavicle. 
If  the  operation  is  done  for  disease,  drainage  will  be  necessary  at  the 
dependent  portions  of  the  incision.  The  edges  of  the  incision  may  be 
opened  or  gaped  with  round  gauze  pads  extending  through  the  skin,  fat, 
and  superficial  muscle.  Tubes  are  placed  between  these  to  the  deepest 
portion  of  the  cavity. 

The  weight  of  the  arm  and  shoulder  is  borne  on  a  wire  shoulder  shelf 
(see  figures  314  and  315),  holding  the  arm  abducted  ninety  degrees  and 
outwardly  rotated  sixty  degrees.  Motion  of  the  forearm,  wrist  and  fingers 
is  encouraged  on  the  shelf  after  ten  days.  As  the  arm  acquires  strength, 
the  shelf  is  lowered  gradually  and  motions  of  the  arm,  active  and  passive, 
are  encouraged  without  the  shelf. 

246.  Methods  and  Principles  of  Drainage  in  Acute  Non-tubercular 
Suppurative  Joint  Disease.  Shoulder. — A  small  suppurative  focus 
without  virulence  or  active  constitutional  disturbance  should  be  drained 
by  a  suitable  incision  wiped  out  with  gauze,  a  tube  placed  to  its  deepest 
part  and  the  soft  tissues  gaped  with  gauze. 

When  there  is  a  great  deal  of  constitutional  disturbance  drainage  and 
counter  drainage  should  always  be  the  rule;  if  the  bone  is  involved  this 
should  be  opened  and  counter  opened  as  shown  (see  figure  66).  The 
pus  cavities  in  the  soft  tissues  should  be  wiped  out.  No  extensive  bone 
operation  should  be  done  otherwise.  The  bone  should  be  drained  with 
tubes  to  the  remote  portions  and  the  muscle,  fat,  and  skin  gaped  by  gauze. 
These  operations  are  done  quickly  and  should  not  be  prolonged,  but 
efficient  drainage  and  counter  drainage  should  be  established  unhesi- 
tatingly. It  is  rarely  necessary  to  do  more  at  this  time.  If  there  is 
a  marked  sequestra  formation  this  should  be  removed,  but  this  had  bet- 
ter not  be  done  at  the  time  of  instituting  drainage  when  the  patient  is 
nearly  exhausted  from  an  acute  process.  Any  future  operation  made 
necessary  should  give  good  drainage  and  the  removal  of  the  sequestra 
if  present  and  separated.    See  the  Carrell-Dakin  technique,  section  323. 


PART  V— ELBOW 
CHAPTER  I 

OPERATION   FOR   DEFORMITIES  AND   DISLOCATION   OF   THE   ELBOW 

247.  Dislocations  of  the  Elbow. — Dislocations  of  the  elbow  should 
be  treated  early.  The  bones  may  be  reached  by  two  lateral  incisions 
each  four  inches  long,  or  by  a  posterior  incision  internal  to  the  olecranon 
five  inches  long  with  an  external  lateral  just  anterior  to  the  condyle  over 
the  radial  joint  and  extending  upward  four  inches. 

Dislocations  of  long  standing  are  difficult  to  replace  and  may  require 
an  excision  or  arthroplasty.  Each  case  will  differ  more  or  less  but  any 
case  unreduced  after  six  weeks  is  apt  to  have  pretty  substantial  adhe- 
sions, rendering  reduction  difficult  or  impossible.  When  accurate  re- 
placement is  impossible  an  arthroplasty  or  excision  should  be  done 
without  delay.  The  surgeon  should  avoid  rough  manipulation  in  at- 
tempting reduction  as  this  will  complicate  the  recovery  from  the  opera- 
tion which  he  adopts  later. 

If  an  open  operation  is  necessary,  the  bones  are  brought  into  view  and 
the  tissues  lifted  from  the  bone.  The  soft  tissues  are  separated  en  masse 
from  the  capsule  fairly  completely,  keeping  close  to  the  bone  subperios- 
teally  as  described  under  excision  of  the  elbow,  (see  Excision,  sections  269, 
276).  Instead  of  removing  any  bone  the  joint  must  be  replaced  accu- 
rately. The  elbow  is  put  up  at  right  angles  for  ten  days  and  then  flexed 
to  forty-five  degrees  from  the  right  angle.  Passive  motion  is  begun 
gently  after  the  first  seven  or  ten  days. 

248.  Manipulation  of  the  Elbow  Joint. — In  manipulation  for  flexi- 
bility of  the  elbow,  the  motion  in  flexion  and  extension  should  be  done 
with  the  forearm  pronated  and  with  the  forearm  supinated.  The  mo- 
tions of  the  radius  at  the  elbow  should  be  tested  in  supination  and  in 
pronation  with  the  elbow  extended  with  the  elbow  flexed  and  with  the 
elbow  at  right  angle. 

The  flexion  and  extension  of  the  wrist  is  manipulated  in  a  pronated 
position  and  in  a  supinated  position;  the  adduction  and  abduction  of 
the  wrist  in  a  pronated  position  and  in  a  supinated  position  and  so  on. 

In  manipulating  for  the  flexibility  of  the  fingers  the  wrist  should  be 
flexed,  then  extended  for  each  manipulation.  The  manipulation  should 
be  done  with  the  forearm  pronated  and  repeated  with  it  supinated. 

The  normal  motion  of  the  joint  should  be  remembered.  The  stretch- 
ing of  the  resisting  tissues  made  gradually  with  a  rhythmic  stretching  and 
relaxing,  the  force  being  applied  gently  and  increased  to  a  climax  and 

217 


218  TECHNIQUE  OF  OPERATIONS 

gradually  decreased  until  there  is  complete  relaxation.  The  joint  is 
stretched  and  relaxed,  the  operator  applying  force  in  a  gradually  in- 
creasing manner  until  considerable  force  is  applied  and  then  relaxing 
until  very  slight  force  is  used  and  finally  relaxing  entirely.  In  this 
manner  a  rhythmic  extension  and  flexion  is  kept  up.  No  rough  or  forcible 
extension  without  a  gradually  increasing  or  gradually  decreasing  force 
should  be  employed.  By  this  method  a  minimum  amount  of  trauma 
is  caused.  Forcible  pumping  motions  are  to  be  avoided.  A  joint  that 
at  first  will  seem  almost  impossible  to  move  will  often  give  way.  Be- 
fore any  extensive  operation,  a  fairly  normal  action  in  all  normal  direc- 
tions  should  be  obtained. 

249.  Plaster  of  Paris  for  the  Elbow. — A  plaster  of  Paris  at  the  elbow 
may  be  put  on  with  the  arm  straight  or  with  the  elbow  flexed  at  any 
angle.  The  palm  of  the  hand  and  the  space  to  the  outer  side  of  the 
second  metacarpal  should  be  well  padded  so  that  the  plaster  may  be 
carried  between  the  thumb  and  index  finger  over  the  second  metacarpal 
but  not  in  such  a  way  as  to  interfere  with  the  motion  of  the  thumb  and 
index  finger  or  the  other  fingers.  This  hand  portion  of  plaster  will 
maintain  the  desired  pronation  or  supination  of  the  forearm.  The 
wrist  and  elbow  should  be  very  well  padded,  but  the  plaster  should  fit 
the  humerus  from  end  to  end  and  the  forearm  from  end  to  end. 


CHAPTER   II 

MUSCLE   AND   TENDON    OPERATIONS.       MUSCLE   AND   TENDON 
TRANSPLANTATION 

250.  Transplantation  of  the  Triceps  for  Paralysis  of  the  Biceps. — 

— When  the  biceps  is  paralyzed  and  the  triceps  is  good  and  strong,  the 
outer  half  of  this  muscle  may  be  transplanted  into  the  paralyzed  biceps 
as  follows. 

OPERATION 

An  incision  is  made  over  the  back  of  the  upper  arm  starting  at  the 
junction  of  the  middle  and  upper  third  extending  downward  over  the 
olecranon.  The  skin  and  fat  are  retracted  exposing  the  outer  third  of 
the  tendon  of  the  triceps.  This  is  divided  and  dissected  from  the  bone 
to  the  above  olecranon,  here  it  is 
expanded  into  half  of  the  triceps 
muscle.  The  outer  half  of  tri- 
ceps is  dissected  up  to  a  little 
above  the  middle  of  the  arm. 
An  incision  is  now  made  over 
the  front  and  middle  of  the 
biceps  down  to  this  muscle,  this 
is  split  with  a  blunt  dissector 
and  a  tunnel  made  extending 
backward  to  the  posterior  in- 
cision. A  tendon  carrier  or  clamp  is  passed  backward  through  the  tunnel, 
grasps  the  tendon  of  the  triceps  bringing  it  forward  through  the  opening 
of  the  biceps.  Silk  is  now  quilted  up  one  side  and  down  the  other  of  the 
triceps  tendon.  An  incision  is  now  made  over  the  front  of  the  elbow 
extending  over  the  inner  side  of  the  biceps  tendon  and  to  its  fascial  ex- 
pansion below.  The  incision  should  expose  the  lower  end  of  the  biceps 
muscle  as  well.  A  subcutaneous  tunnel  is  now  made  below  the  fat  con- 
necting the  two  anterior  incisions.  A  tendon  carrier  is  now  passed  up- 
ward from  the  lower  to  the  upper  incision  and  brings  with  it  the  silk 
and  tricep  tendon.  The  silk  is  now  quilted  into  the  bicep  tendon  and 
fascia  and  the  lower  end  of  the  biceps  muscle  sutured  to  the  tricep, 
the  elbow  being  flexed  twenty  degrees  beyond  a  right  angle. 

The  deep  tissues  and  fat  are  sutured  with  interrupted  catgut  sutures, 
the  skin  with  chromic  catgut  number  00.  A  plaster  of  Paris  bandage 
is  applied  holding  the  elbow  flexed  slightly  more  than  a  right  angle. 


Fig.  363. — Humerus  drilled,  leader  of  silk  worm- 
gut  placed  in  drill  eye. 


219 


CHAPTER  III 


OPERATION  IN  CASES  OF  TOTAL  OR  PARTIAL  PARALYSIS 


251.  Flail  Condition  of  the  Elbow. — When  a  flail  condition  of  the 
elbow  exists,  silk  ligaments  may  be  used  to  hold  the  joint  at  right  angles 
or  an  arthrodesis  may  be  done,  otherwise  it  will  be  necessary  to  use  a 
brace  to  hold  the  elbow  at  right  angles  in  order  that  the  hand  may  be 
used.     An  apparatus  is  often  sufficient  and  very  comfortable. 

252.  Silk  Ligament  at  the  Elbow. — If  silk  ligaments  are  to  be  used 
they  are  inserted  as  described  for  the  ankle  (see  also  figures  363  to  368). 

253.  Fascia  Transplantation  for  Flail  Condition  of  the  Elbow. — 

OPERATION 

An  incision  is  made  three  inches  long  over  the  anterior  lower 
third  of  the  humerus,  and  extending  through  the  skin  and  fat.     What 


Fig.  364. — Silk  wormgut  drawn  through  the 

humerus.     Drill    used   to   draw   silk   subcuta- 

neously  to  the  forearm.  Fig.  365.— Drill    passed    through    the 

ulna.  Silk  from  the  humerus  threaded 
through  the  silk  wormgut  leader. 


Fig.  366. — Silk  protruded  from  the 
forearm,  one  has  passed  through  the 
ulna,  the  other  comes  from  the 
humerus. 


Fig.   367. — Diagram  of  silk  ligaments 
in  paralysis  at  the  elbow. 


remains  of  the  atrophied  fibers  of  the  biceps  and  brachealus  anticus 
fibers  are  separated  by  a  blunt  dissector  and  retracted  exposing  the 
bone.  A  large  hole  is  drilled  in  the  humerus  through  the  anterior  third 
of  the  bone  and  a  silk  wormgut  guide  (figure  363),  passed  through  the 

220 


OPERATION  IN  CASES  OF  TOTAL  OR  PARTIAL  PARALYSIS    221 

bone  by  means  of  the  drill  which  should  be  made  with  an  eye.  A  second 
incision  is  made  four  inches  long  over  the  middle  of  the  upper  half  of 
the  forearm  through  the  skin  and  subcutaneous  fat.  The  atrophied 
muscles  are  easily  separated  and  the  ulnar  bone  exposed  and  drilled. 
A  silk  wormgut  guide  is  passed  through  the  bone. 

Removal  of  fascia  from  the  fascia  lata 

An  incision  five  or  six  inches  long  is  made  on  the  middle  and  outer 
aspect  of  the  thigh  down  to  the  fascia  lata;  by  retracting  the  skin  and 
fat  which  is  very  elastic,  a  piece  of 
fascia  broader  and  longer  than  the 
incision  may  be  obtained.  The 
amount  necessary  should  be  care- 
fully measured  by  a  probe  and  an 
extra  two  inches  allowed.  The  fascia 
removed  is  slit  at  each  end  and  its 
edges  rolled  (figure  294).    A  tunnel  is 

,      .       . ,  i  c   ,  Fig.  368. — Incisions  closed. 

made  in  the  subcutaneous  fat  con- 
necting the  two  arm  incisions,  the  fascia  passed  through  this  and  its  ends 
(figure  295),  passed  through  the  bone  above;  the  lower  ends  through 
the  bone  below.  The  ends  are  overlapped  and  sutured  with  interrupted 
chromic  catgut  sutures  number  00  (figure  296).  If  the  operator  pre- 
fers, these  ends  are  sutured  to  the  deep  fascia  or  to  silk  passed  through 
the  bone  (figure  297).  The  elbow  should  be  flexed  fifteen  degrees  be- 
yond what  is  desired  so  that  the  fascia  will  hold  it  flexed  slightly  more 
than  right  angles.  There  will  be  a  stretching  of  about  twenty-five  de- 
grees in  time. 

After  treatment 

A  posterior  wire  splint  or  plaster  of  Paris  bandage  is  applied  holding 
the  elbow  in  sufficient  flexion  to  take  all  tension  off  of  the  fascia.  A  large 
roll  of  loose  cotton  is  placed  over  the  front  of  the  arm  and  arranged  as 
in  tendon  operation  on  the  leg.  The  original  position  should  be  main- 
tained eight  weeks.  If  a  plaster  of  Paris  bandage  is  used  the  front  half 
may  be  removed  and  a  gauze  bandage  applied  to  hold  on  the  posterior 
half.  In  this  way  the  wound  may  be  inspected  readily.  After  six  weeks 
the  weight  of  the  forearm  is  allowed  to  pull  on  the  fascia  from  five  to 
fifteen  minutes  twice  a  day  in  increasing  doses.  Then  later  four  times 
increasing  every  third  day,  until  the  forearm  is  carried  without  apparatus 
two  hours  at  a  time.  After  this  the  strain  of  holding  the  forearm  is 
increased  rapidly. 

254.  Operation  on  the  Skin  for  a  Flail  Elbow,  (Mr.  Jones'  operation) . — 
The  patient  lies  on  his  back,  the  extended  arm  is  placed  on  a  table. 

An  incision  is  made  diamond  shaped  through  the  skin  and  fat  and  sub- 
cutaneous tissue  over  the  front  of  the  arm,  the  skin  removed  and  sutured 
so  that  the  upper  and  lower  angles  of  the  diamond  come  in  contact 


2  .'2 


TECHNIQUE  OF  OPERATIONS 


with  each  other,  holding  the  arm  at  flexion  twenty  degiees  more  than 
right  angles. 

Before  incising  the  skin,  a  heavy  piece  of  silk  is  passed  through  the 
skin  (see  figures  359,  360),  at  the  selected  upper  angle  and  another  at 
the  selected  lower  angle  of  the  diamond.  These  are  brought  together 
so  that  the  operator  may  judge  the  amount  of  stretching  that  will  take 
place  when  the  weight  of  the  forearm  is  allowed  to  come  on  the  skin. 
When  this  is  determined,  a  diamond  shaped  piece  of  skin  is  marked  out 
with  its  upper  end  on  the  anterior  aspect  of  the  lower  third  of  the  upper 
arm  and  the  lower  angle  of  the  diamond  will  be  in  the  upper  third  of  the 
forearm.  These  points  will  have  been  determined  by  the  silk  inserted 
in  the  skin  and  made  to  hold  the  arm  in  the  desired  position  before  incis- 
ing the  skin.    This  will  decide  the  proper  distance  between  the  upper 


Fig.  369. — Diamond  shaped 
skin  incision;  the  outer  edges  are 
approximated  and  then  the  inner 
edges  approximated. 


Fig.   370. — Edges  of    the  dia- 
mond are  brought  together. 


and  lower  ends  of  the  diamond.  The  test  will  also  determine  the  shape 
of  the  diamond.  The  operator  will  remove  less  skin  than  is  required. 
More  is  then  removed  to  hold  the  elbow  flexed  twenty  degrees  beyond 
right  angle. 

After  treatment 

A  plaster  of  Paris  bandage  or  posterior  wire  splint  will  relieve  tension 
on  the  skin  until  it  is  healed.  This  should  remain  for  eight  weeks.  It 
is  then  removed  fifteen  minutes  twice  daily,  later  four  times  a  day  and 
increased  every  three  days  until  the  patient  has  the  motion  of  the  fore- 
arm without  the  splint  for  two  hours  twice  daily;  after  that  the  progress 
is  more  rapid. 

255.  Arthrodesis  of  a  Flail  Elbow.— If  a  rubber  bandage  and  tourni- 
quet are  to  be  used,  the  surgeon  should  have  the  tourniquet  put  on  care- 
fully and  not  too  tight  and  have  it  removed  as  early  as  possible.  A  towel 
should  be  put  under  the  tourniquet. 

The  patient  lies  on  his  back,  the  arm  across  his  thorax.  The  operator 
stands  on  the  same  side  as  the  arm  to  be  operated  on.    A  posterior  inci- 


OPERATION  IN  CASES  OF  TOTAL  OR  PARTIAL  PARALYSIS    223 

sion,  four  inches  long  is  made,  starting  two  inches  above  the  tip  of  the 
olecranon  and  extending  vertically  downward  to  the  triceps.  The  fibers 
of  the  triceps  are  separated  carefully  and  a  subperiosteal  dissection  is 
made,  exposing  the  sides  and  back  of  the  humerus  and  of  the  ulna. 
The  joint  capsule  is  opened,  the  olecranon  is  chiselled  off  with  an 
osteotome  through  the  middle  of  the  sigmoid  cavity  and  the  end  dis- 
placed upwards;  the  joint  is  denuded  of  cartilage  and  roughened. 

The  trochlea  surface  may  be  split  from  below  upwards,  the  edge  of  the 
osteotome  being  parallel  to  the  intracondylar  line.  The  broadening  of 
the  trochlea  surface  and  the  roughening  of  the  bone  in  consequence  favors 
ankylosis.  The  olecranon  is  held  in  place  by  suturing  the  periosteum  or 
by  silver  wire.  The  separated  olecranon  may  be  fastened  to  the  hu- 
merus by  silk  or  silver  wire  preventing  extension  of  the  arm.  The  deep 
tissues  are  carefully  brought  together  with  interrupted  chromic  catgut 
sutures  number  00,  the  triceps  likewise,  the  subcutaneous  fat  with  in- 
terrupted chromic  catgut  sutures  number  00,  the  skin  with  continuous 
chromic  catgut  sutures  number  00.  The  arm  should  be  put  up  extended 
fifteen  degrees  or  twenty  degrees  from  a  right  angle  position  and  held 
here  by  a  firm  plaster  of  Paris  bandage  with  windows  for  the  inspection 
of  the  incisions.  In  most  instances  apparatus  is  preferable  to  an  opera- 
tion when  a  flail  elbow  exists.  It  is  well  to  remember  that  the  surgeon 
is  not  always  gratified  when  attempting  to  get  ankylosis  at  the  elbow, 
though  under  other  circumstances  a  stiff  elbow  is  not  uncommon. 


CHAPTER  IV 

INCISION,    PUNCTURE   AND    ARTHROTOMY 

256.  Artnrotomy. — A  knowledge  of  the  important  routes  of  ap- 
proach to  the  joints  will  facilitate  any  joint  exploration,  the  removal  of 
foreign  bodies,  the  repair  of  traumatic  conditions,  the  adjustment  of 
difficult  fractures,  the  reduction  of  old  and  difficult  dislocations,  the 
mobilization  of  joints  where  motion  is  partially  or  totally  lost,  and  the 
stiffening  of  the  joint  as  in  certain  paralytic  conditions,  the  treatment 
and  drainage  of  suppurative  conditions;  a  knowledge  of  the  important 
routes  of  approach  to  the  joint  is  very  important.  For  each  case,  the 
operator  will  select  the  incision  best  suited  for  the  individual  condition. 
Each  joint  will  be  considered  separately  in  other  chapters. 

In  all  operations  on  the  joints,  the  incision  should  be  made  down  to 
the  synovial  cavity.  All  bleeding  should  be  stopped  and  the  synovial 
membrane  carefully  opened.  The  joint  structures  should  be  tampered 
with  as  little  as  possible,  the  synovial  membrane  brought  together 
carefully  and  the  layers  over  it  closed  in  order  not  to  disturb  the  func- 
tion of  the  periarticular  tissues.  Unnecessary  separation  of  the  tissue 
layers  is  to  be  avoided.  Tendons  should  be  left  in  their  sheath.  Any 
ligaments  that  must  be  cut  should  be  loosened  periosteally,  in  order 
that  they  may  be  readily  replaced.  Early  motion  should  be  the  rule, 
gentle  at  first,  and  gradually  increased.  Joint  operations  should  never 
be  hastily  considered  and  should  be  avoided  by  anyone  not  familiar 
with  the  best  surgical  technique. 

In  exploratory  operations  at  the  elbow,  erasions,  excisions,  or  arthro- 
desis, or  dislocations,  for  draining  suppurative  conditions,  either  the 
posterior  or  the  external-lateral  supplemented  at  the  same  time  by  an 
internal  incision  are  the  routes  preferred. 

The  operator  stands  on  the  side  of  the  arm  to  be  operated  upon.  The 
arm  is  placed  across  the  patient's  thorax.  The  incision  is  made  four 
inches  long  starting  two  inches  above  the  tip  of  the  olecranon  and 
slightly  to  the  outer  side  of  the  middle  line.  The  fibers  of  the  triceps 
are  divided  carefully  in  the  line  of  the  incision.  The  dissection  is  car- 
ried down  to  the  bone  and  through  the  periosteum.  By  means  of  a 
long  handled  osteotome  or  a  sharp  periosteum  elevator  the  periosteum 
is  removed,  working  to  the  outer  side,  clearing  the  condyle  from  above 
downward. 

257.  Posterior  Incision  (see  figure  371). — The  posterior  incision  is 
made  vertically  to  the  outer  side  of  the  olecranon  or  to  the  inner  side. 
The  outer  incision  is  preferable  for  excision,  arthroplasty,  fractures  of 
the  olecranon,  of  the  outer  condyle,  and  exploratory  operations  on  the 

224 


INCISION,  PUNCTURE  AND  ARTHROTOMY 


225 


joint.  For  dislocations,  the  incision  may  be  made  to  the  inner  side  of 
the  olecranon  and  be  supplemented  by  an  external  incision  over  the  con- 
dyle slightly  anterior.  Some  surgeons  prefer  two  lateral  incisions  for 
dislocations  and  for  arthroplasty.  The  anterior 
incision  is  a  more  hazardous  route  than  the 
lateral  or  the  posterior  and  is  rarely  necessary. 
The  anterior  route  follows  the  outer  edge  of  the 
biceps  tendon  down  to  the  capsule. 

The  posterior  incision  begins  two  inches  above 
the  olecranon  and  extends  vertically  downward 
about  four  inches.  It  is  made  to  the  outer  side 
of  the  olecranon.  The  dissection  is  carried  down 
to  the  bone.  The  periosteum  is  incised  and  the 
tissues  lifted  with  it.  A  long  handled  osteotome 
is  used  for  this  purpose  or  a  sharp  periosteal 
elevator  with  a  good  handle.  The  periosteum 
is  started  at  the  upper  end  of  the  incision  and 
raised,  working  downward  until  the  lower  end 
of  the  incision  is  reached;  the  operator  then 
works  at  that  end  and  goes  upward  and  outward, 

raising  the  periosteum  from  the  bone  until  the      Fig.  371.  —  Posterior  in- 
outer  Condyle  is   cleared.      The   Surgeon  should    cision  along  the  inner  side  of 
•  i  r  £  ,1  •      j  the  olecranon  extending  four 

avoid  roughness  in  forcing  up  the  periosteum.   inches  above  and  four  inches 
The  work  at  this  point  is  largely  one  of  dili-  below  the  joint, 
gence.     The  outer  condyle  is  cleared  first  then  the  inner  condyle  (see 
Excision,  section  276). 

258.  External  Lateral  Incision  (see  figure  372). — This  incision  is 
made  parallel  to  the  bone  extending  over  the  head  of  the  radius  and 

upward  five  inches,  just  anterior  to  the 
condyle.  The  dissection  is  made  care- 
fully down  to  the  bone,  the  radial  joint 
opened  if  neces- 
sary and  the  per- 
iosteum raised 
from  the  condyle 
starting  over  the 

Fig.  372.— External  lateral  incision    head     of     the 
over   the   condyle   and   head   of  the    radius       working 

radms-  upward  and  for- 

ward until   the  upper  end  of   the   incision  is  incision  just  posterior  to 
reached.      The  operator  raises  the  periosteum  the  internal  condyle. 
here,  then  works  gradually  downward  and  then  upward  lifting  all  the 
tissues  subperiosteally;  after  clearing  the  bone  anteriorly  he  may  clear 
off  the  periosteum  posteriorly,  depending  on  the  exposure  necessary. 

259.  Internal  Lateral  Incision   (see  figure  373). — This  incision  is 
made  four  inches  long  extending  two  inches  above  and  two  inches  below 


Fig.  373.— Internal  lateral 


220 


TECHNIQUE  OF  OPERATIONS 


the  condyle  and  slightly  posterior  to  it.  The  position  of  the  ulnar 
nerve  must  be  remembered.  The  periosteum  is  lifted  under  it  so 
that  it  is  not  seen  during  the  process  of  lifting  the  periosteum.  The 
operator  clears  the  condyle  as  far  as  necessary  anteriorly  and  then 
posteriorly. 

260.  Anterior  Incision  for  Reaching  the  Elbow  Joint. — This  incision 
is  rarely  necessary  and  is  not  as  practical  as  the  posterior  or  lateral.  It 
is  made  to  the  outer  side  of  the  tendon  of  the  biceps, 
following  down  through  the  bicipital  fascia.  A  blunt 
dissector  is  used  to  separate  the  tissue  below  this 
until  the  capsule  is  reached  (see  figure  374). 

261.  Operations  for  Fractures  at  the  Elbow. — 
Operations,  when  necessary,  for  fractures  at  the  elbow, 
should  be  done  as  early  as  possible.  In  all  compound 
fractures  where  the  condition  of  the  patient  allows, 
the  compound  wound  should  be  opened  up  and 
thoroughly  cleansed.  If  opening  up  the  compound 
wound  does  not  give  a  good  approach  for  treatment 
of  the  fracture,  one  of  the  above  incisions  may  be 
utilized  in  addition.  Quantities  of  irrigation  with 
sterile  water  or  sterile  salt  solution  together  with 
wiping  out  of  the  wound  with  gauze  strips  will  usually 
be  sufficient  to  give  a  first  intention  healing.  The 
operator  will  have  to  select  the  incision  best  suited 
for  the  individual  fracture.  It  is  important  to  re- 
rior  incision"  along  member  that  there  will  be  better  healing  with  a  long 
the  outer  side  of  the  vertical  incision  than  with  a  transverse  incision.  The 
bicipital  fascia.  tissues  should  not  be  separated  in  layers  but  be  kept 

together  on  either  side  of  the  incision.  No  method  should  be  adopted 
that  will  increase  the  amount  of  repair  necessary  or  interfere  unduly 
with  the  circulation.  Plenty  of  room  is,  however,  necessary.  If  the 
swelling  is  great,  it  will  be  difficult  to  put  the  fracture  up  at  an  acute 
angle  to  the  desirable  position  which  assures  the  proper  adjustment  of 
the  fragments.  It  is  often  better  for  this  reason  not  to  operate  until  the 
swelling  has  subsided;  in  the  meantime  the  elbow  is  immobilized  at 
right  angles. 

The  necessity  of  immediate  operation  in  fractures  about  the  joints 
depends,  as  in  other  fractures,  on  the  acuteness  of  the  local  and  gen- 
eral reaction.  When  these  do  not  contra  indicate  immediate  opera- 
tion, certain  fractures  about  the  joints  may  require  treatment  by  the 
open  method.  Among  these  are  fractures  of  the  patella,  fractures  of 
the  olecranon  and  certain  fractures  of  the  surgical  neck  of  the  hu- 
merus and  certain  fractures  of  the  neck  of  the  femur,  all  compound 
fractures,  even  when  the  protrusion  of  the  bone  has  been  extremely 
slight,  all  fractures  that  cannot  be  reduced  by  manipulation  or  in  which 
the  correction  cannot  be  maintained  or  where  apposition  is  impossible, 


INCISION,  PUNCTURE  AND  ARTHROTOMY 


227 


many  fractures  combined  with  dislocation,  articular  fractures  with  pieces 
locking  or  limiting  the  joint  action. 

Where  there  is  a  great  deal  of  trauma  and  in  multiple  fractures  and  in 
cases  where  there  is  a  great  deal  of  shock  all  that  can  be  done  is  to  im- 
mobilize the  parts  until  a  favorable  time  for  operation.  In  selecting  a 
suitable  time  for  operation  the  surgeon  must  remember  that  when  it  is 
found  necessary  to  operate  on  a  fracture  if  there  is  no  immediate  contra 
indication,  the  sooner  it  is  done  the  better.  Where  there  is  tremendous 
swelling  one  should  always  wait.  All  cases  should  be  operated  on  that 
show  no  union  after  three  months  of  good  treatment. 


Fig.  375. — Portable  traction 
-pa  apparatus  applied  for  fractures 
-*-^  of  the  upper  extremity.  A,  Can- 
vas belt.  B,  Rod  which  can  be 
taken  apart.  C,  Two  double 
block  pulleys.  E,  Broad  web- 
bing, doubled  and  passed 
around  the  flexed  forearm  over 
a  pad  (H).  J,  Traction  rod 
hooked  to  canvas  belt. 

262.  A  Traction  Apparatus  for  Fractures  at  the  Elbow  (see  figures 
375  to  379). 

Note. — (This  apparatus  may  be  used  for  fractures  of  the  shoulder  and  fractures 
of  the  shaft  of  the  humerus.) 

In  fractures  and  dislocations  of  the  elbow  and  the  lower  end  of  the 
humerus,  when  the  displacement  is  very  marked,  replacement  is  diffi- 
cult without  a  good  deal  of  injury  to  the  tissues. 

The  following  apparatus  has  been  found  of  service  in  that  it  minimizes 
the  trauma  of  reduction.  It  makes  the  alignment  of  a  fracture  a  matter 
of  regulated  precision.  The  apparatus  may  be  used  in  open  operations 
and  in  reducing  a  fracture  or  dislocation  without  incision ;  it  may  be  used 
in  fractures  of  the  elbow,  humerus  and  shoulder  whenever  traction  is 


228 


TECHNIQUE  OF  OPERATIONS 


an  advantage  with  or  without  incision  to  adjust  the  fractures  to  wire, 
bone  plate,  or  bone  graft.  The  apparatus  consists  of  a  canvas  belt 
(see  figure  A),  two  double  two  inch  block  pulleys  (see  figure  C),  and  a 
rod  five  feet  long  and  three-fourths  of  an  inch  in  diameter  (see  figure  B), 
bent  at  both  ends  with  a  hook  at  each  tip.  This  rod  is  made  in  three 
sections  so  that  it  may  be  easily  carried. 

For  use  without  incision  (See  figure  375.) 

A  canvas  belt  is  placed  around  the  patient's  thorax  high  up  under 
the  axilla.  This  serves  to  hold  one  end  of  the  rod  making  traction  on 
the  arm  as  follows: — the  patient  is  anaesthetized 
and  lies  on  the  operating  table  or  bed,  the  traction 
rod  is  placed  over  the  front  of  the  chest  (see  fig- 
ure B).  One  end  is  hooked  to  the  canvas  belt  at 
the  side  opposite  the  fracture  (see  figure  J).  The 
other  end  extends  nearly  four  feet  from  the  side  of 
the  operating  table.  A  heavy  pad  (see  figure  H) 
consisting  of  one  or  two  pillow  cases  folded,  is 
placed  over  the  upper  end  of  the  forearm.  Around 
this  is  placed  a  webbing  strap,  doubled  (see  fig- 
ure E) .  Pulleys  are  attached  from  the  free  end  of 
the  traction  rod  to  the  webbing  around  the  upper 
end  of  the  flexed  forearm.  Traction  is  then  ap- 
plied with  the  elbow  flexed  at  right  angles. 
When  the  overlapping  is  corrected,  traction  is 
maintained  while  the  surgeon  moves  the  frag- 
ments forward  or  back  or  laterally,  as  the  case 
requires.  The  traction  can  be  increased  or  di- 
minished easily  and  gradually  without  jarring  the 
parts.  The  perfect  control  is  effected  by  two 
two-inch  double  block  pulleys  (see  figure  C). 
Single  block  pulleys  are  not  satisfactory.  The 
surgeon  manipulates  the  bones  while  he  directs 
the  assistant  managing  the  traction.  A  pull  of 
one  inch  on  the  rope  will  move  the  fragments  one- 
fourth  of  an  inch, 
transverse  supracondylar  When  the  fracture  or  dislocation  is  adjusted,  the 
fractures.  2a,  2b,  oblique  webbing  on  the  upper  forearm-  is  moved  to  the 

f£T*c£?ofSttene?£'  wrist  while  the  elbow  is  Sreased  or  Powdered  if 
necessary.    The  webbing  is  then  replaced  over  its 

pad  and  the  final  adjustment  made  by  applying  traction  again.     The 

elbow  is  then  flexed  to  an  acute  angle  or  put  in  a  position  selected  by  the 

surgeon  and  held  there  by  him  while  the  retentive  dressing  is  applied. 

When  traction  is  released  the  surgeon  maintains  his  hold  on  the  arm,  the 

webbing  on  the  forearm  of  the  patient  is  removed  by  sliding  it  up  over  the 

wrist  and  hand  to  the  forearm  of  the  surgeon  or  it  may  be  unbuckled  and 


INCISION,  PUNCTURE  AND  ARTHROTOMY  229 

removed  if  no  longer  needed.  This  apparatus,  in  connection  with  a  trac- 
tion machine  for  operations  on  the  leg,  was  devised  about  twelve  years 
ago  by  the  writer.  It  should  be  noted  that  while  making  traction  the 
forearm  strap  must  not  slide  off  the  pad  nor  the  elbow  allowed  to  become 
acutely  flexed. 

Use  of  the  apparatus  for  open  operations  On  fractures  or  dislocation  of 
the  elbow  (See  figures  377,  378.) 

Note. — (This  apparatus  can  be  used  in  fractures  of  the  shoulder  and  shaft.) 

This  apparatus  is  used  as  described  above  when  an  open  operation 
is  necessary.  In  order  not  to  interfere  with  the  asepsis  of  the  operation, 
the  traction  rod  is  placed  across  the  operating  table  covered  with  a  pil- 
low and  the  patient  placed  over  the  pillow.    This  places  the  rod  behind 


Fig.  377. — Represents  the  apparatus  ready  to  be  covered  with  sterile  sheets 
for  open  operations,  the  arm,  arm  pad  and  webbing  (A)  being  sterilized. 

the  patient  instead  of  in  front,  its  end  protruding  at  the  side  of  the  oper- 
ating table  nearly  four  feet.  One  end  of  the  traction  belt  is  hooked  to 
the  canvas  belt  as  described  above.  The  arm  and  hand  are  cleaned  up, 
made  sterile,  and  protected  as  usual  with  sterile  sheets.  The  folded 
pillow  case  or  small  sheet  which  is  to  be  used  as  a  pad  on  the  forearm 
is  sterilized  beforehand.  The  webbing  for  traction  on  the  forearm  is  also 
sterilized.  This  webbing  should  extend  at  least  a  foot  from  the  elbow 
after  being  doubled  and  looped  over  the  padded  forearm.  The  loop  of 
webbing  is  next  attached  to  the  pulley  and  covered  by  a  sterile  sheet 
pinned  to  it  and  clamped  so  that  the  webbing  touching  the  pulley  and 
the  pulley  cannot  be  exposed  during  the  application  and  removal  of 
traction  while  operating.  This  sterile  sheet  protection  allows  the 
operator  to  remove  completely  and  re-apply  the  loop  of  webbing  from 
the  forearm  without  disturbing  the  asepsis.  The  traction  rod  and  pa- 
tient are  protected  by  sterile  sheets  (see  figure  378).  Traction  may  be 
applied  and  released  during  the  operation  without  exposure  of  any  non- 
sterile  material. 


230 


TECHNIQUE  OF  OPERATIONS 


Where  the  trauma,  due  to  the  accident,  has  been  great,  it  is  better 
in  the  case  of  certain  fractures  to  wait  from  five  to  seven  days  to  allow 
the  swelling  to  subside  before  replacing  the  fracture.  The  fracture  is 
immobilized  during  the  interval.  It  is  of  advantage  in  these  cases,  where 
the  displacement  is  great,  in  replacing  the  fracture,  to  cause  as  little 
trauma  and  consequent  after  swelling  as  possible,  following  the  reduc- 
tion. This  apparatus  is  especially  valuable  for  this  purpose.  When  the 
fragments  are  finally  adjusted,  this  method  is  sufficiently  free  from 
trauma  to  cause  little  and  in  some  cases  practically  no  additional  swell- 
ing following  its  use. 

Most  fractures  of  the  elbow,  excepting  fractures  of  the  olecranon,  are 
best  held  with  the  elbow  at  an  acute  angle.  This  position  is  not  always 
a  desirable  one  at  the  time  of  injury  on  account  of  the  swelling.  Over- 
lapping bones,  with  lateral  and  antero-posterior  displacement  at  the 


Fig.  378. — Represents  the  apparatus  covered  with  sterile  sheets,  represented  by  cross 
lines.  Traction  at  (K)  is  made  by  a  non-sterile  assistant.  The  sterilized  webbing  (A) 
can  be  removed  from  the  arm  and  replaced. 

elbow,  are  difficult  to  replace  without  causing  a  good  deal  of  swelling 
which,  if  it  occurs,  may  make  it  necessary  to  abandon  the  acute  flexion 
position  so  desirable  in  many  elbow  fractures. 

By  means  of  this  apparatus,  used  when  the  swelling  has  largely  sub- 
sided, there  need  be  very  little  additional  swelling  following  reduction, 
making  the  use  of  the  acutely  flexed  position  comparatively  free  from 
danger  and  free  from  acute  pain.  The  adjustment  is  under  perfect 
control  making  very  perfect  reduction  possible. 

Methods  of  treating  the  individual  fracture  cannot  be  considered  in 
a  limited  space  like  this.  The  writer  has  described  the  routes  of  ap- 
proach to  the  different  joints  and  the  technique  of  these.  This  will  en- 
able the  surgeon  from  his  knowledge  of  fractures  to  select  the  route  best 
adapted  for  the  individual  treatment  required  and  when  necessary  two 
or  more  incisions  may  be  used.  A  knowledge  of  the  technique  will  en- 
able the  surgeon  to  work  rapidly  in  reaching  the  fracture  on  which  he 
expects  to  spend  time. 


INCISION,  PUNCTURE  AND  ARTHROTOMY 


231 


263.  A  Method  of  Treating  Overlapping  Fractures.— Where  the 
bones  overlap,  an  excellent  method  of  treatment  is  one  suggested  to  the 
writer  many  years  ago  by  Dr.  Edward  Martin  of  Philadelphia.  In  the 
operation  when  the  surgeon  has  reached  the  fracture  the  bone  is  freed. 
A  tough  tape  or  webbing  is  used  ten  or  twelve  feet  long,  sterilized.  The 
two  ends  of  the  tape  are  tied  together,  a  loop  of  the  tape  is  placed  over 
the  distal  end  of  the  bone.  The  other  end  of  the  tape  is  thrown 
over  the  foot  of  the  operating  table,  a  thirty-five  pound  weight  is 
attached  to  this  by  an  assistant.  In  about  five 
minutes  the  bones  will  be  found  to  be  separated  at 
least  one  inch.  The  weight  is  then  held  up  by  a 
non-sterile  assistant,  the  tape  taken  off  of  the  end 
of  the  bone  and  clamped  to  the  sheet  on  the 
operating  table,  so  that  it  will  not  slip  away  while 
the  surgeon  works  on  the  fracture.  When  the 
muscles  are  in  fairly  good  tone  or  the  overlapping 
of  bone  has  been  great,  it  will  be  found  that  the 
bones  will  overlap  again  in  four  or  five  minutes. 
A  reapplication  of  the  tape  will  separate  the  bones 
again  for  the  same  length  of  time.  The  end  of  the 
lower  bone  should  not  be  cut  or  freshened  until 
all  other  procedures  are  done  which  require  separa- 
tion of  the  bone.  When  these  have  all  been  done 
the  end  of  the  bone  over  which  the  tape  has  been 
placed  is  freshened.  After  this  the  tape  should  not 
be  placed  on  the  end  of  the  bone  unless  it  is  very  nec- 
essary, but  the  two  ends  allowed  to  come  together 
and  held  by  a  clamp  until  the  operation  is  complete. 

Very  bad  overlapping  fractures  have  been  treated 
in  this  way  in  fresh  cases  without  the  necessity  of 
shortening  the  bone.  In  old  fractures  no  more 
bone  need  be  removed  than  is  required  by  the 
conical  condition  of  the  ends  of  the  bone. 

264.  Fractures  of  Long  Standing  Still  Unu- 
nited or  United  with  Deformity,  Preventing 
Function. — In  fractures  of  long  standing  where 
there  is  a  mild  infection  conservative  treatment  should  be  tried  first. 
When  this  has  been  tried  free  drainage  should  be  established  and  at  the 
same  time  the  ends  of  the  bone  freshened  up  slightly.  Unless  the 
infection  is  marked,  in  many  of  these  cases  when  the  suppuration  dis- 
appears, union  has  also  taken  place.  In  any  case  where  there  has  been 
infection,  no  plastic  operation  should  be  used  until  the  infection  has  been 
entirely  absent  for  at  least  nine  months,  a  year  is  safer.  Where  the  infec- 
tion is  very  mild  and  of  long  standing,  during  the  process  of  treatment 
the  patient  may  be  allowed  to  walk  on  the  other  leg  if  the  local  reaction 
is  not  too  great.    Sometimes  he  may  walk  a  little  on  the  affected  leg. 


Fig.  379. —  These 

fractures  may  be  treated 
by  the  traction  appara- 
tus (see  figure  377) ,  with 
or  without  open  incision. 


232  TECHNIQUE  OF  OPERATIONS 

It  is  of  advantage  in  certain  cases  to  use  a  Thomas  splint  to  take  some  of 
the  weight  off  of  the  affected  leg,  the  patient  being  allowed  to  bear 
weight  on  the  ball  of  the  foot,  the  splint  taking  all  the  weight  off  of  the 
heel.  Where  the  x-ray  shows  conical  ends  of  the  bones  it  is  practically 
useless  to  expect  union,  without  surgical  interference.  If  there  is  much 
swelling  in  fractures  about  the  elbow,  the  arm  may  need  to  be  held  at 
right  angles  until  it  has  subsided,  but  as  a  rule  the  acute  flexion  assures 
correction  of  the  displaced  fragments.  When  they  are  not  readily  re- 
placed, an  open  incision  is  made  to  the  bone.  The  surgeon  chooses  the 
incision  best  adapted  to  the  fracture  and  goes  down  through  the  peri- 
osteum exposing  the  bone  subperiosteally  and  adjusting  the  fragments 
when  the  bone  is  well  exposed. 

265.  Irreducible  Dislocation  and  in  Multiple  Fractures  of  the  Elbow. 
— After  severe  injuries  with  multiple  fractures  at  the  elbow  and  in  ir- 
reducible dislocations  of  the  elbow,  it  is  often  necessary  to  do  an  excision 
or  an  arthroplasty  in  those  cases  that  do  not  yield  to  the  usual  methods  of 
conservative  treatment.     See  sections  289  and  292. 

266.  Overlapping  Fractures  of  Both  Bones  of  the  Forearm. — When 
there  is  a  fracture  of  both  bones  of  the  forearm,  it  is  often  possible  to  ob- 
tain good  apposition  without  an  incision.  However,  the  overlapping 
fracture  is  a  very  difficult  one  to  reduce  and  to  hold  after  reduction. 
When  treated  by  the  open  method,  it  requires  the  greatest  care  and  pre- 
cision. One  bone  is  apt  to  displace  while  the  other  is  being  adjusted. 
To  avoid  this,  the  method  of  reduction  is  described  with  some 
detail. 

When  a  satisfactory  reduction  is  not  obtained  shortly  after  the  acci- 
dent, an  incision  is  almost  always  necessary.  If  the  fracture  is  fairly  re- 
cent, that  is  to  say,  within  three  weeks,  good  union  may  be  expected 
after  reduction.  An  incision  is  made  for  each  bone  separately,  the  skin 
and  fat  separated  in  one  layer.  It  is  made  at  the  side  of  the  arm  in  order 
not  to  be  pressed  on  by  the  splints.  The  overlapping  bones  should  be 
treated  as  described  elsewhere,  for  overlapping  fractures.  The  tape 
placed  on  the  ends  of  the  bone  will  readily  separate  them  with  a  min- 
imum amount  of  trauma.  Each  bone  should  be  placed  in  position. 
Following  this,  sutures  are  placed  through  the  skin  and  fat  without 
closing  the  wound.  These  sutures  are  not  tied.  The  long  suture  ends 
are  clamped  and  held  aside  so  that  the  fractures  may  be  readily  in- 
spected. One  assistant  holds  the  wrist,  and  another  the  elbow,  while  the 
surgeon  takes  a  final  view  of  one  fracture,  and  then  the  other.  If  nec- 
essary, the  surgeon  should  re-adjust  the  fracture  before  closing  the  in- 
cisions, the  arm  is  held  steadily  by  the  two  assistants,  while  the  sutures 
are  being  tied  and  other  superficial  sutures  are  placed  without  moving 
the  arm.  They  do  not  relax  their  hold  until  the  splints  and  bandages 
are  applied.  Sterile  sheet  wadding  is  placed  evenly  around  the  arm. 
The  anterior  and  posterior  splints  are  applied  without  disturbing  the 
fracture.    An  internal  angular  splint  is  applied  or  else  a  plaster  of  Paris 


INCISION,  PUNCTURE  AND  ARTHROTOMY  233 

bandage  to  immobilize  the  elbow.  The  plaster  should  be  put  around 
the  two  forearm  splints  but  later  half  of  it  cut  away  below  the  splints, 
This  allows  the  elbow  and  the  splints  to  be  inspected.  After  in- 
spection, the  elbow  is  flexed  again,  and  the  two  splints  slide  into 
place  in  the  plaster  and  are  bandaged  there.  In  judging  the  ten- 
sion of  the  splints  the  surgeon  presses  the  splints  together  at  the 
points  where  the  adhesive  is  placed.  If  the  adhesive  will  wrinkle 
slightly  it  is  not  too  tight.  The  splints  should  fit  the  arm  per- 
fectly at  the  side  and  have  ten  to  twelve  thicknesses  of  sheet 
wadding. 

No  foreign  substance  as  a  rule  need  be  used  to  hold  the  bones, 
unless  the  fracture  is  of  long  standing,  in  which  case  it  is  better  to  use  a 
bone  graft  than  bone  plates  for  one  bone  at  least.  The  bones  are  chiselled 
apart  and  the  ends  fastened.  Where  the  tape  method  of  treating  over- 
lapping fractures  is  used  it  is  not  necessary  to  shorten  the  bone  unless 
the  fracture  is  old  and  the  x-ray  shows  that  the  ends  are  conical.  (See 
sections  262,  263.)  Following  the  operation,  the  fracture  should  be 
viewed  at  the  end  of  five  days  and  then  every  second  or  third  day 
by  removing  the  posterior  splint ;  any  tendency  to  bowing  should  be  ad- 
justed by  small  pads.  Otherwise  the  fracture  is  treated  like  a  simple 
fracture  of  both  bones. 

267.  Fractures  of  the  Olecranon. — When  a  fracture  of  the  olecranon 
is  treated  by  a  splint  holding  the  arm  straight,  it  may  heal  without 
surgical  interference.  It  should  be  operated  on  early  if  the  fragments 
cannot  be  easily  replaced  or  if  they  have  been  separated  a  week  or  more. 
If  left  any  length  of  time  the  fragments  are  apt  to  heal  and  the  ends  will 
not  fit  as  well.  A  "U"  shaped  incision  or  a  long  posterior  incision  is 
used  to  the  outer  side  of  the  fracture  through  the  skin  and  fat.  These 
are  retracted  and  the  incision  carried  down  to  the  bone  in  the  median 
line.  Any  clot  is  wiped  out.  The  fractured  ends  are  brought  together 
and  fitted,  then  the  bone  is  drilled.  The  drill  is  inserted  through  one 
fragment;  as  the  tip  protrudes  the  fragments  are  put  together.  The 
drill  point  is  made  to  mark  the  point  of  entry  in  the  second  fragment. 
The  drill  is  then  withdrawn  from  the  first  fragment  and  is  used  at  the 
marked  point  to  drill  the  second  fragment.  Kangaroo,  phospho  bronze 
or  silver  wire  may  be  used  to  fasten  the  fragments  together  perferably 
at  first.  The  arm  is  put  up  straight  and  flexed  slightly  at  the  end  of  ten 
days,  the  flexion  is  increased  gradually,  until  it  reaches  a  right  angle  in 
three  weeks.  At  the  end  of  six  weeks  if  it  will  not  flex  forty-five  degrees 
beyond  the  right  angle,  it  should  be  manipulated  gently  under  an  anaes- 
thetic and  placed  in  an  acute  angle  and  held  by  adhesive  or  a  figure  of 
eight  bandage  for  a  few  days.  As  long  as  the  thumb  can  reach  the 
shoulder,  the  arm  may  be  allowed  more  extension.  Should  it  become 
difficult  to  reach  the  shoulder,  with  the  thumb,  the  adhesive  is  tempo- 
rarily shortened  preventing  extension  beyond  a  point  from  which  this 
flexion  is  easy. 


234  TECHNIQUE  OF  OPERATIONS 

268.  Tapping  the  Elbow  Joint. — The  most  scrupulous  aseptic  pre- 
cautions are  necessary  both  as  to  the  preparation  and  the  protection  of 
the  field  of  the  operation. 

The  elbow  is  flexed  at  right  angles,  the  trocar  enters  the  joint  just 
anterior  to  the  external  condyle  above  the  head  of  the  radius.  The  proc- 
ess is  rendered  easier  when  there  is  much  swelling.  An  assistant  or  the 
operator  presses  on  the  joint  anteriorly  to  make  the  joint  as  full  as  pos- 
sible at  the  point  of  tapping.  The  elbow  being  fully  flexed,  the  joint  may 
be  tapped  above  the  olecranon.  Local  anaesthesia  may  be  sufficient  but 
the  use  of  gas  or  primary  ansesthesis  is  preferable  if  any  injections  are 
to  be  made. 

When  there  is  much  effusion  it  is  not  difficult  to  reach  the  joint.  The 
skin  is  drawn  to  the  side  so  that  the  hole  in  the  skin  and  muscle  will  be 
out  of  line  when  the  needle  is  removed.  If  fluid  is  to  be  drawn,  and  other 
solutions  are  to  replace  it,  the  amounts  should  be  carefully  measured. 
Two  good  graduated  metal  syringes  are  very  useful.  All  of  their  parts 
should  be  tested  beforehand.  The  trocar  is  made  to  enter  the  joint  and 
then  is  connected  with  the  syringe.  As  little  air  as  possible  should 
enter  the  joint.  The  trocar  should  be  of  large  diameter  as  the  fluid  may 
be  thick  or  flaky.  When  the  patient  is  not  anaesthetized  for  the  opera- 
tion it  is  often  well  to  have  a  short  flexible  tube  connect  the  trocar  with 
the  syringe.  This  should  be  fastened  at  both  ends  by  silk  ties  so  that 
it  will  not  leak  easily  when  pressure  or  suction  is  used.  If  the  joint  is 
to  be  washed  out  a  definite  amount  of  fluid  is  injected  and  the  return 
measured  in  a  sterilized  measuring  glass. 

Dr.  Murphy  uses  a  formalin  glycerine  solution  as  follows: — Liquor 
formaldehyde  2%  in  glycerine,  about  ten  drops  of  the  formaldehyde  to 
each  ounce  of  glycerine. 

This  acts  very  well  in  infectious  synovitis,  but  it  should  not  be  used 
in  arthritis  deformans  nor  in  chronic  arthritis. 

The  tapping  may  be  done  with  ethyl  chlorid  or  novocaine  adreneline 
solution  1%.  The  solution  should  be  prepared  twenty-four  hours  before 
it  is  used  (Murphy). 


CHAPTER  V 

OPERATION    IN    CASES    OF    ANKYLOSIS    OF    THE    ELBOW 

269.  Excision  or  Ankylosis  for  the  Elbow. — Ankylosis  of  the  elbow 
may  be  congenital  or  as  a  result  of  trauma  or  suppurative  arthritis. 
These  may  be  of  bone  origin,  articular,  or  periarticular,  causing  thick- 
ening or  scar  formation.  Ankylosis  may  be  caused  by  injuries  and  frac- 
tures, irreducible  fractures  or  dislocations  of  the  humero-radial  or  of  the 
humero-ulnar  joint. 

Excision  or  arthroplasty  is  indicated  for  ankylosis  from  whatever 
cause  which  does  not  yield  to  conservative  measures,  provided  no  disease 
has  existed  for  over  a  year.  When  tuberculosis  has  existed,  an  arthro- 
plasty is  not  as  good  an  operation  as  an  excision;  neither  should  be  done 
unless  some  muscular  power  is  present.  In  some  cases  when  there  is 
power  this  may  develop  and  an  operation  done  when  the  muscle  seems 
strong  enough  for  future  function. 

For  ankylosis  of  the  radial  joint,  an  excision  of  the  head  of  the  radius 
is  possible  through  a  very  small  incision.  The  bone  is  removed  by  a  small 
osteotome  and  a  fat  and  fascia  flap  or  a  muscular  flap  turned  in  between 
the  bones.    See  section  276. 

270.  Synostosis  at  the  Elbow. — A  synostosis  of  the  bones  of  the 
forearm,  either  congenital  or  acquired,  is  often  difficult  to  treat.  The 
operator  should  make  long  incisions  that  will  gape  easily.  The  dissec- 
tion should  be  made  to  the  bone  carefully  without  separating  the  layers 
on  either  side  of  the  incision.  In  this  way  a  minimum  amount  of  injury 
is  possible  to  the  tendons  and  other  important  structures  and  the  condi- 
tion will  be  readily  exposed  and  dealt  with  without  injury  to  the  soft 
tissues. 

271.  Arthroplasty  for  Ankylosis  at  the  Elbow. — Ankylosis  may  be 
bony,  cartilaginous  or  fibrinous,  it  may  be  periarticular,  ligamentous 
and  capsular,  or  extra  articular,  that  is,  skin  scars,  tendons,  fascia, 
nerves  and  arteries. 

The  form  of  ankylosis  that  exists  will  determine  the  treatment.  A 
partial  ankylosis  at  certain  points  had  better  not  be  treated  by  an  ar- 
throplasty. 

Age  must  be  considered,  also  the  general  condition  of  the  patient. 
When  the  ankylosis  is  bony,  cartilaginous  or  fibrinous,  arthroplasty 
is  indicated.  When  the  condition  is  periarticular  or  extra  articular,  it 
may  be  treated  by  capsulotomy,  tendon  elongation,  excision  of  exostosies, 
etc. 

Dr.  Murphy  lays  stress  on  the  following  points: — The  principles  of 
asepsis  to  the  finest  detail  are  absolutely  essential.     One  not  familiar 

235 


236  TECHNIQUE  OF  OPERATIONS 

with  the  best  surgical  technique  should  avoid  arthroplasty  operations. 
The  exposure  of  the  joint  must  be  generous  and  complete.  The  con- 
tracted capsular  ligaments  and  soft  parts  must  be  freed  and  if  necessary 
lengthened.  The  normal  contour  of  the  joint  should  be  restored  as  near 
as  possible.  The  operator  should  obtain  a  hyper-mobilization  of  the 
joint.  The  joint  should  be  re-shaped  to  give  stability.  The  inter- 
position of  material  to  prevent  reunion  of  the  bone  is  necessary. 

The  principle  is  to  separate  the  bones  and  to  interpose  between  them 
material  to  prevent  ankylosis.  The  best  material  for  this  purpose  is  the 
human  pedicle  composed  of  fat,  muscle,  fascia  or  a  combination  of  these. 

When  this  is  not  possible,  a  transplantation  is  made  of  fat  and  fascia 
from  the  trochanter  bursa  region  or  from  the  fascia  lata. 

Material  such  as  ivory,  celluloid,  silver  are  not  good.  Materials  that 
will  not  absorb  or  that  absorb  too  slowly  are  not  desirable. 

During  the  operation  the  soft  parts  should  be  freely  liberated.  Attach 
the  interposing  flap  to  one  bone  only  and  cover  it  completely.  Early 
motion,  that  is,  at  the  end  of  five  to  seven  days  is  necessary  with  or 
without  gas  or  gas  and  oxygen. 

Dr.  Murphy  records  failures  in  arthroplasty  as  due  to  first,  insufficient 
and  defective  exsection  of  the  capsule  and  ligaments,  second,  insufficient 
interposition  of  fat  and  fascia  between  the  separated  bony  surfaces, 
third,  infection,  fourth,  the  sensitiveness  to  pain  or  motion  after  opera- 
tion. 

Cases  of  primary  tuberculois  and  cases  of  recent  infection  that  have 
subsided  are  not  suitable  cases  for  arthroplasty.  In  operation,  in  addi- 
tion to  the  usual  protection  of  the  field  of  operation,  after  the  skin  and 
fat  have  been  incised,  towels  should  be  clamped  to  the  edges  of  the  skin 
as  an  extra  protection. 

272.  Arthroplasty  for  Ankylosis  at  the  Elbow. — The  patient  lies  on 
his  back,  the  operator  stands  on  the  side  of  the  arm  to  be  operated  on. 
The  shoulder  is  adducted  and  flexed  and  inwardly  rotated. 

An  incision  is  made  six  inches  long  with  its  middle  at  the  olecranon. 
Two  lateral  are  preferable,  one  may  be  sufficient.  In  any  extensive 
injury  which  has  caused  the  ankylosis,  the  operator  may  either  stick 
very  closely  to  the  bone  and  avoid  seeing  the  ulnar  nerve  or  he  may  find 
the  ulnar  nerve  and  free  it.  Whenever  the  scar  tissue  does  not  extend 
to  the  bone,  and  is  not  great,  it  is  better  to  stick  close  to  the  bone  and 
not  see  the  nerve.  After  freeing  the  humerus  and  ulna  as  described 
in  these  pages  for  an  Excision  (see  Operation  for  Excision),  the  bones 
are  separated  as  there  described,  the  olecranon  will  have  to  be  sacrificed 
as  it  will  interfere  with  the  plastic  operation.  After  shaping  the  hu- 
merus and  ulna  so  that  they  conform  to  the  normal  joint  outlines,  a  flap 
is  taken  from  the  uponurosis  of  the  supinator  longus  and  interposed  be- 
tween the  bones  or  the  operator  may  prefer  to  use  a  portion  of  the  fat 
and  fascia  on  the  inner  side  of  the  arm.  In  either  case  the  base  of  the 
flap  is  directed  upward.     The  flap  should  reach  completely  across  the' 


OPERATION  IN  ANKYLOSIS  OF  THE  ELBOW  237 

joint  and  be  wide  enough  to  cover  it.  If  there  is  an  ankylosis  as  is  often 
the  case,  between  the  radius  and  the  lesser  sigmoid  cavity,  a  portion  of 
the  bone  must  be  removed  here  and  muscle  interposed.  When  the  ulnar 
nerve  has  been  found  to  be  fastened  down  firmly  with  scar  tissue  to  the 
bone  and  when  any  extensive  dissection  has  been  necessary  to  free  it, 
it  should  be  replaced  in  its  groove  at  the  end  of  the  operation  well  sur- 
rounded with  fat.  The  arm  should  be  held  in  a  right  angle  position  for 
about  a  week  and  motion  begun  after  that  a  little  twice  a  day.  In  ten 
days  apparatus  is  removed  and  a  sling  worn.  Where  the  operation  has 
been  carefully  done,  it  is  usually  necessary  to  gain  flexion  rather  than 
extension. 

In  the  after  treatment  the  operator  should  work  to  gain  flexion  first. 
When  the  extended  and  abducted  thumb  can  touch  the  humerus,  this 
motion  should  be  preserved  while  motion  in  extension  is  being  encour- 
aged. 

The  further  treatment  depends  on  exercises,  and  physical  therapy 
such  as  baking  and  massage. 

273.  Overhead  Sling  for  the  Arm  Following  Operation. — The  arm 
may  be  held  vertically  or  horizontally  by  an  overhead  sling.  A  long 
stick  of  wood  like  a  broom  handle  is  attached  in  a  vertical  position  to 
the  post  at  the  foot  of  the  bed.  The  upper  end  should  be  about  five 
or  six  feet  from  the  floor,  another  is  placed  at  the  middle  of  the  head  of 
the  bed  in  the  same  way.  A  light  window  cord  is  drawn  tightly  between 
the  ends  of  the  two  sticks,  the  arm  is  held  off  of  the  bed  by  a  bandage 
attached  to  the  rope.  The  suspended  arm  should  be  placed  in  a  com- 
fortable position. 


CHAPTER  VI 

OPERATION   FOR   SUPPURATIVE   CONDITIONS 

274.  Suppurative  Conditions,  about  the  Elbow. — A  posterior  inci- 
sion either  side  of  the  olecranon,  avoiding  the  ulnar  nerve,  combined  with 
a  lateral,  just  anterior  to  the  external  condyle,  to  drain  the  radial  joint 
will  be  sufficient  for  the  majority  of  extensive  suppurative  conditions. 

At  the  elbow  it  is  important  in  extensive  joint  suppuration  to  open 
anteriorly  as  well  as  posteriorly  and  not  forget  the  radial  joint.  See 
Carrell-Dakin  Technique,  section  323. 

The  principles  otherwise  are  the  same  as  those  laid  down  for  other 
joints. 

275.  Osteomyelitis. — In  osteomyelitis  an  operation  should  be  done 
as  early  as  possible  after  making  the  diagnosis.  In  sub-acute  cases, 
incision  and  drainage  are  all  that  is  necessary.  Whenever  incising  for 
abscess  all  the  pockets  should  be  opened  and  if  the  abscess  is  large, 
counter  incisions  are  made  at  dependent  portions.  The  pus  pocket 
should  be  opened  freely,  wiped  out  with  gauze,  irrigated  and  wiped  out 
again  with  gauze.  Curetting  should  be  avoided  excepting  for  the  re- 
moval of  sinuses  in  the  skin  and  in  cases  of  sinuses  it  is  often  better  to 
excise  them.  Perforated  rubber  tubing  should  be  placed  to  drain  the 
deepest  portion  of  each  pocket.  The  skin,  fat  and  superficial  muscle 
layers  should  be  made  to  gap  by  means  of  gauze  drains.  At  the  end  of 
ten  days  the  gauze  is  removed  and  the  tubes  shortened.  The  tubes  are 
gradually  drawn  out  a  little  each  day  or  two  until  not  used.  This 
method  makes  the  repeated  reapplication  of  drains  and  wicks  unneces- 
sary as  the  wound  will  gap  of  itself  and  close  from  the  bottom  if  the 
surgeon  has  been  careful  to  make  large  incisions. 

Where  the  periosteum  is  found  destroyed  or  there  is  pus  under  the  peri- 
osteal layer,  the  bone  should  be  opened  by  means  of  a  large  drill  or  a 
small  gouge.  Where  this  is  necessary,  the  incisions  should  be  large  and  a 
counter  incision  should  be  made  on  the  other  side  of  the  bone  with  a 
hole  made  in  the  bone  a  little  above  or  below  the  hole  on  the  opposite 
side  (figure  66) .  These  holes  in  the  bone  should  open  up  the  medullary 
cavity.  They  should  alternate  on  one  side  and  the  other  as  far  up  and 
down  as  the  disease  is  suspected.  When  the  abscess  is  very  great  and 
the  bone  involvement  is  large  a  number  of  good  sized  holes  should  be 
made  with  a  Burr  drill  or  a  curved  gouge  on  both  sides  of  the  bone  as 
shown  in  figure  67.  The  wound  should  be  gaped  widely; — the  skin, 
fat  and  superficial  muscle  held  wide  open  by  large  gauze  drains.  The 
tubes  should  reach  from  the  surface  to  the  deepest  portions  of  the  ab- 
scess cavity.     Splints  should  always  be  applied  to  immobilize  the  limb. 

238 


OPERATION  FOR  SUPPURATIVE  CONDITIONS  230 

They  should  be  placed  so  that  they  will  not  interfere  with  the  dressing. 
In  some  instances  it  is  better  to  apply  a  plaster  with  large  windows 
and  ropes  to  give  stability  as  shown  in  figures  450  to  460.  The  dress- 
ings should  be  done  every  day  or  twice  a  day,  depending  on  the 
foul  condition  of  the  discharge.  If  the  odor  is  excessive  chlorinated 
soda  dressing  should  be  used  diluted,  1/z,  ]/-3  or  1/i  the  U.  S.  P. 
strength.  The  gauze  drains  should  remain  for  at  least  ten  days  without 
being  disturbed.  When  removed  granulations  will  be  formed  under 
them  in  such  a  way  as  to  keep  the  wound  open  without  applying  drains. 
Irrigation  may  be  used  at  the  time  of  the  operation  and  the  wound 
thoroughly  wiped  out  with  gauze  afterwards.  No  irrigation  or  probing 
or  application  of  wicks  will  be  necessary  if  the  first  drains  are  left  in 
long  enough.  After  the  first  ten  days  the  tubes  are  shortened  gradually 
until  they  are  not  needed. 

In  severe  cases  where  the  patient  is  unconscious  or  delirious  the  bone 
should  always  be  opened,  three  or  four  holes  on  either  side  made  with  a 
good  sized  Burr  drill  or  gouge.  In  severe  cases  the  incision  should 
be  made  on  both  sides  of  the  leg  always.  No  tight  packing  should  be 
used  as  this  interferes  with  good  drainage.  Where  sequestra  have 
formed  they  should  be  removed.  An  x-ray  should  be  taken  whenever 
possible  to  determine  the  position  of  the  disease  (unless  the  case  is  ur- 
gent and  an  immediate  x-ray  is  not  obtainable). 

In  cases  of  long  standing  that  are  sub-acute  at  the  time  of  first  exam- 
ination, where  the  bone  is  riddled  with  holes  over  an  extremely  long 
area,  it  is  impossible  often  to  remove  the  dead  bone  satisfactorily  with- 
out removing  all  the  bone.  In  these  cases  free  incision  down  to  the 
bone  with  frequent  openings  into  the  bone  as  described  above,  will 
allow  the  infection  to  run  its  course  and  the  sequestra  to  gradually 
separate.  We  have  had  some  cases  in  which  the  lower  third  of  both 
femora  were  riddled  with  holes  and  full  of  sequestra,  the  patient  being 
in  no  condition  for  extensive  operation,  and  yet  not  very  ill.  In  these 
cases,  however,  if  the  surgeon  had  seen  the  patient  in  time  an  early 
operation  would  have  prevented  this  extreme  condition. 

Sometimes  it  is  necessary  to  close  a  large  open  bone  cavity  which 
will  not  heal  over.  Where  the  process  is  distinctly  infected  no  plastic 
operation  should  be  done  without  first  doing  an  operation  to  eliminate 
the  infection.  After  that,  part  of  the  muscle  may  often  be  trans- 
ferred over  such  a  cavity  to  close  it.  In  transferring  a  muscle  over  such 
a  cavity  it  should  be  freely  transplanted  and  held  there  without  ten- 
sion. The  skin  should  be  brought  together  over  the  muscle  and  the 
wound  drained. 

Where  sequestra  are  present  it  is  always  desirable  to  remove  them  as 
soon  as  they  have  separated  and  the  involucrum  is  strong  enough  to  act 
as  a  support.  Sequestra  may  be  superficial  or  in  the  medullary  cavitj7 
or  both.  Where  there  is  a  persistent  sinus  and  a  sequestrum  is  present, 
pus  will  continue  to  form  until  the  sequestrum  is  removed.     Cases 


240  TECHNIQUE  OF  OPERATIONS 

discharging  several  years  where  a  sequestrum  is  present  may  close  in 
a  few  weeks  after  removal  of  the  sequestrum. 

To  close  a  bone  cavity  its  edges  may  be  chiselled  clean,  then  the  bone 
incised  a  short  distance  from  one  edge  and  parallel  to  it,  the  incision  is 
carried  down  to  the  medulla,  the  incision  in  the  bone  is  widened  by 
prying  it  open  and  forcing  the  bone  together  and  closing  the  old  cavity. 
This  is  sometimes  a  satisfactory  method  of  closing  an  old  open  bone 
cavity  which  has  sclerosed  edges.  See  Carrell-Dakin  technique,  sec- 
tion 323. 

276.  Excision  of  the  Elbow  for  Suppuration.  (See  Fig.  371.) — An 
incision  is  made  starting  two  or  three  inches  above  the  olecranon  and 
to  its  outer  side  extending  vertically  downward  two  or  three  inches 
below  it.  The  skin  and  fat  are  separated  and  the  triceps  muscle  fibers 
separated  down  to  the  bone.  The  periosteum  is  incised  and  peeled 
off  the  outer  condyle  of  the  humerus  above  and  downward  to  the  ole- 
cranon and  off  of  this  and  the  ulna  extending  outward  so  that  the  whole 
of  the  external  condyle  is  exposed  subperiosteally.  After  this,  the  in- 
ternal condyle  is  cleared  in  the  same  way,  a  long  handled  osteotome 
being  used  for  the  purpose.  The  ulnar  nerve  must  be  avoided;  it  is  per- 
fectly safe  if  the  operator  will  stick  below  the  periosteum,  it  will  not 
come  into  view.  The  olecranon  is  chiselled  off 
the  joint  opened.  The  humerus  is  cleared  next 
anteriorly  and  laterally.  In  case  of  ankylosis 
it  is  sometimes  easier  to  clear  the  ulna  and 
radius.  When  the  joint  is  separated  it  is  easy  to 
keep  up  the  subperiosteal  dissection  by  bringing 
the  humerus  out  of  the  wound  and  then  the 
ulna  and  radius.  The  diseased  bone  is  removed 
with  a  saw  just  at  the  upper  part  of  the  condyles 
removing  one-half  inch  from  the  condyles  (see 
figure  380)  and  just  through  the  base  of  the 
head  of  the  radius  removing  the  head  of  the 
radius  and  the  ulna  at  the  same  level  (see 
figure  380) ;  this  should  be  removed  with  a  saw. 
Fig.  380.  —  Excision  of  Rongeurs  are  used  to  remove  the  sharp  edge  of 
the  elbow,  line  marking  the  the  bone,  any  further  disease  is  cut  out  with  a 
bone  to  be  removed.  chisel?    cutting   the    healthy   bone   around   it. 

Enough  bone  should  be  removed  with  the  saw  to  allow  very  free 
mobility  of  the  joint.  The  disease  in  the  soft  tissues  is  dissected 
out  completely.  The  triceps  and  all  the  tissues  have  remained  unexposed 
between  the  periosteum  and  the  skin.  They  are  now  brought  together 
and  carefully  sutured.  The  periosteum  and  the  muscles,  the  fat  and 
the  skin  layer  by  layer,  covering  the  end  of  the  radius  with  muscle  to 
prevent  adhesions. 

A  puncture  is  made  one  inch  long  over  the  other  side  of  the  joint  where 
the  head  of  the  radius  was  situated.    This  and  a  similar  internal  poste- 


OPERATION  FOR  SUPPURATIVE  CONDITIONS  241 

rior  drainage  point  is  usually  sufficient  in  suppurative  cases.  The  triceps 
will  repair  and  be  ready  for  future  usefulness.  The  elbow  is  immobilized 
at  right  angles  in  plaster  and  the  elbow  may  be  suspended  by  a  bandage 
to  an  overhead  trolley,  held  there  after  operation.  Later  the  elbow  is 
acutely  flexed.  Pronation  and  supination  and  flexion  are  begun  a  little 
on  the  tenth  day. 

The  arm  should  be  allowed  to  flex  but  no  extension  beyond  a  right 
angle  allowed  until  the  muscles  are  strong  enough  to  flex  completely 
and  extend  easily  to  a  right  angled  position. 

277.  Methods  and  Principles  of  Drainage  in  Acute  Non-tubercular 
Suppurative  Joint  Disease.  Elbow. — A  small  suppurative  focus  with- 
out virulence  or  active  constitutional  disturbance  should  be  drained  by 
a  suitable  incision  wiped  out  with  gauze,  a  tube  placed  to  its  deepest 
part  and  the  soft  tissues  gaped  with  gauze.     See  section  323. 

When  there  is  a  great  deal  of  constitutional  disturbance  drainage 
and  counter  drainage  should  always  be  the  rule;  if  the  bone  is  involved 
this  should  be  opened  and  counter  opened  (figure  66) .  The  pus  cavities 
in  the  soft  tissues  should  be  wiped  out.  No  extensive  bone  operation 
should  be  done  otherwise.  The  bone  should  be  drained  with  tubes  to 
the  remote  portions  and  the  muscle,  fat  and  skin  gaped  by  gauze. 
These  operations  are  done  quickly  and  should  not  be  prolonged,  but 
efficient  drainage  and  counter  drainage  should  be  established  unhesi- 
tatingly. It  is  rarely  necessary  to  do  more  at  this  time.  If  there  is 
a  marked  sequestra  formation  this  should  be  removed,  but  this  had  bet- 
ter not  be  done  at  the  time  of  instituting  drainage  when  the  patient  is 
nearly  exhausted  from  an  acute  process.  Any  future  operation  made 
necessary  should  give  good  drainage  and  the  removal  of  the  sequestra  if 
present  and  separated.     The  joint  should  be  immobilized. 

Any  extensive  non-tubercular  suppurative  bone  disease  about  the 
elbow  should  be  drained  by  a  posterior  and  an  antero-lateral  external 
incision  or  by  both  of  these  and  an  internal  lateral.  If  the  patient  is 
very  ill  and  the  abscess  in  the  bone  not  easily  located,  large  incisions 
are  made  to  the  bone  and  the  bone  drilled  or  not,  as  the  case  demands. 
The  operation  should  be  done  very  rapidly  and  good  drainage  estab- 
lished. For  chronic  suppuration  or  tuberculosis  an  excision  is  often  in- 
dicated when  conservative  treatment  has  been  unsuccessful. 


PART  VI— WRIST  AND  BAND 
CHAPTER  I 

DEFORMITIES   OF  THE   WRIST    AND    HAND 

278.  Operation  for  Madelung's  Deformity. — An  incision  is  made 
down  to  the  bones  of  the  carpus  and  projecting  bone,  the  bones  are 
exposed  subperiosteal^  and  enough  of  the  carpus  removed  to  allow  the 
prominent  bone  to  slip  into  place.  The  incisions  are  closed,  the  tendons 
retracted  without  disturbing  them  in  the  tissues. 

A  plaster  and  then  a  leather  should  be  worn  for  about  three  months. 
This  apparatus  should  allow  the  use  of  the  fingers  and  hand  but  im- 
mobilize the  wrist.  The  carpal  joints  beyond  the  wrist  will  increase  in 
motion  and  make  up  for  some  of  the  restriction  of  motion  which  follows 
the  operation. 

279.  Club  Hand  Operation. — When  the  deformity  is  due  to  absence 
of  one  of  the  bones  of  the  forearm,  a  longitudinal  incision  is  made  over 
the  remaining  bone;  the  latter  is  split  to  receive  the  carpus.  The  carpus 
is  prepared  by  slanting  its  lateral  edges  without  narrowing  it  any  more 
than  is  absolutely  necessary.  The  bone  and  carpus  are  sutured  and  the 
tissue  closed,  the  arm  and  hand  being  held  in  a  plaster  allowing  the 
use  of  the  fingers  and  hand.  As  these  grow  strong  the  support  is  grad- 
ually omitted  after  the  third  or  fourth  month.  The  carpus  usually 
becomes  very  flexible  allowing  about  one-third  of  the  normal  wrist 
flexion  and  extension.  When  both  bones  are  present  bony  union  by 
graft  or  splitting  the  radius  is  usually  necessary  to  prevent  recurrence 
of  the  deformity  of  the  wrist. 

280.  Contracted  Wrist  and  Finger  Operation. — When  the  wrist 
and  fingers  are  contracted  if  there  is  no  disease  present,  the  wrist  may  be 
manipulated  so  that  it  will  extend,  flex,  adduct  and  abduct  in  a  pronated, 
in  a  supinated  position,  and  halfway  between  the  two.  It  is  sometimes 
necessary  to  lengthen  the  tendons  of  the  contracted  muscles  as  described 
in  these  pages.  Where  there  is  much  scar  tissue  in  the  palm  of  the  hand 
or  wrist  it  may  be  necessary  to  excise  this  and  to  transplant  a  flap  from 
the  abdomen.  To  do  this  a  sterile  cloth  is  cut  the  size  of  the  flap  de- 
sired. The  hand  is  placed  over  the  abdomen  in  a  comfortable  position 
without  strain  on  the  shoulder,  elbow  or  wrist.  The  site  of  the  skin  is 
selected,  the  cloth  pattern  is  laid  over  it  and  the  outline  marked  one- 
half  inch  larger  than  is  necessary  all  around.  The  flap  is  dissected  up, 
leaving  two  broad  attachments.  The  hand  is  placed  in  position  and 
the  flap  adjusted  but  not  finally  sutured.     The  hand  is  withdrawn. 

243 


244  TECHNIQUE  OF  OPERATIONS 

If  necessary  one  of  the  broad  attachments  may  be  cut  away  or  they  may 
both  be  left.  The  skin  edges  from  which  the  flap  was  cut  are  now  lifted 
with  the  fat  and  freed  well  from  four  to  six  inches  separating  the  fat 
from  the  underlying  fascia.  This  will  allow  the  skin  to  be  brought  to- 
gether without  tension  under  the  lifted  flap.  Mattress  sutures  over 
gauze  or  over  rubber  tubing  are  used  to  hold  the  edges  without 
tension;  the  skin  and  fat  are  sutured.  The  hand  is  now  placed  in  posi- 
tion over  this  and  the  flap  sutured  to  it  as  planned.  The  upper  arm  and 
forearm  are  separated  from  the  body  by  sterile  towels  and  padding, 
a  swathe  is  placed  over  this  leaving  the  hand  and  flap  exposed,  adhesive 
plaster  is  placed  outside  the  swathe  about  three  strips  three  inches 
broad,  this  will  hold  the  arm  in  place. 

To  return  to  the  hand,  before  the  dressing  is  applied  any  surfaces 
of  skin  that  come  in  contact,  should  be  separated  by  an  intervening 
layer  of  cotton  cloth,  sterilized.  This  is  placed  between  the  palm  and 
the  skin  of  the  abdomen.  The  flap  should  be  sutured  carefully  allow- 
ing no  granulating  areas  excepting  at  the  pedicle  attachment.  If  the 
flap  is  large  its  edges  may  be  brought  together  making  a  cylinder, 
where  it  leaves  the  abdomen.  This  may  be  done  before  finally  placing 
the  hand  in  position.  In  eight  days  the  hand  with  the  graft  is  cut  away 
from  the  abdomen.  The  abdominal  skin  will  be  healed  excepting  a 
small  opening  which  is  closed.  The  skin  edges  are  freshened  before 
suture. 

When  the  contracture  is  of  the  finger  only,  this  may  be  congenital  or 
acquired.  A  rectangular  palmar  skin  flap  is  usually  better  than  a  V- 
shaped  one  though  sometimes  a  V-shaped  one  is  preferable.  When  it 
is  necessary  to  place  a  wolf  graft  from  the  arm  or  leg,  a  square 
end  skin  incision  is  preferable.  The  skin  flap  slides  down  and  the 
tendon  stretched  or  lengthened.  After  operation  for  flexion  of  the  finger, 
the  wrist  should  be  held  flexed  by  means  of  a  dorsal  wire  or  aluminium 
splint  on  the  hand  and  forearm  and  the  fingers  held  extended.  The 
splint  is  used  constantly  for  three  weeks  and  part  of  each  day,  after  that 
for  at  least  six  months. 

281.  Manipulation  of  the  Finger  and  Wrist  Joints. — The  flexion  and 
extension  of  the  wrist  are  manipulated  in  a  pronated  position  and  in  a 
supinated  position;  the  adduction  and  abduction  of  the  wrist  in  a  pro- 
nated position  and  so  on. 

In  manipulating  for  flexibility  of  the  fingers,  the  wrist  should  be  flexed, 
then  extended  for  each  manipulation.  The  manipulation  should  be  done 
with  the  forearm  pronated  and  repeated  with  it  supinated. 

The  normal  motion  of  the  joint  should  be  remembered.  The  stretch- 
ing of  the  resisting  tissues  made  gradually  with  a  rhythmic  stretching 
and  relaxing,  the  force  being  applied  gently  and  increased  to  a  climax 
and  gradually  decreased  until  there  is  complete  relaxation.  The  joint 
is  stretched  and  relaxed,  the  operator  applying  force  in  a  gradually 
increasing  manner  until  considerable  force  is  applied  and  then  relaxing 


DEFORMITIES  OF  THE  WRIST  AND  HAND  245 

until  very  slight  force  is  used  and  finally  relaxing  entirely.  In  this  man- 
ner a  rhythmic  extension  and  flexion  are  kept  up.  No  rough  or  forcible 
extension  without  a  gradually  increasing  or  gradually  decreasing  force 
should  be  employed.  By  this  method  a  minimum  amount  of  trauma  is 
caused.  Forcible  pumping  motions  are  to  be  avoided.  A  joint  that  at 
first  will  seem  almost  impossible  to  move  will  often  yield.  Before  any 
extensive  muscle  or  tendon  operation,  a  fairly  normal  action  in  all  di- 
rections should  be  obtained. 


CHAPTER  II 

MUSCLE   AND   TENDON    OPERATIONS.       MUSCLE   AND    TENDON 
TRANSPLANTATION 


F  i  o. 


-Silk 


282.  Silk  Elongation  for  Cut  or  Short  Tendons  in 
the  Finger. — When  a  tendon  in  the  finger  is  cut  or 
hopelessly  involved  in  scar  contractures  it  is  often 
simpler  to  elongate  with  silk  as  described  below 
rather  than  to  dissect  up  the  tissues  and  separate  out 
the  tendon  from  a  large  mass  of  scar  tissue  to  which 
.  it  will  readily  adhere  again.  This  is  especially  the 
don  at  the  finger  case  when  the  tendon  has  been  cut  and  injured  in 
tip-  several  places. 

OPERATION 

A  small  incision  is  made  three-quarters  to  one  inch  long  on  the 
palmar  surface  of  the  finger  (see  figure  381),  a  number  fourteen  silk 
is  quilted  into  the  fibrous  sheath  about  the  tendon. 
A  second  incision  is  made  in  the  front  of  the  wrist 
above  the  carpal  bones,  a  long  probe  or  director  with 
a  hole  in  its  end  is  passed  from  the  finger  to  the 
wrist  subcutaneously.  A  silk  guide  is  passed  through 
the  e}re  in  the  probe  and  the  silk  withdrawn  with  this 
guide  or  directly  with  the  probe.  The  number  four- 
teen silk  now  reaches  the  wrist.  The  incision  in  the 
finger  is  closed  with  interrupted  chromic  catgut 
number  00  or  with  horse  hair. 

The  flexor  tendons  in  the  wrist  are  exposed  and 
the  proper  one  located  by  pulling  on  the  others  which 

extend  to  the  fingers.    The  silk  is 

now  quilted  into  the  tendon  (see 

figures    382,   383),   which  is   cut 

away  so  that  it  will  be  free  from 

its  distal  attachment,  unless  one 

of  the  free  tendons  to  one  of  the 

other  fingers  is  used.    In  this  in- 


Fig.  382.— Silk  quilted 

into     the     tendon     is 

drawn     to     the    lower 

Stance    the    two    fingers    must    be    forearm    by   means   of 

expected  to  flex  simultaneously.        a  tendon  carrier. 

The  deep  fascia  is  brought  together  with  interrupted 
chromic  catgut  number  00,  the  subcutaneous  fat  with 
interrupted  chromic  catgut  number  00,  the  skin  with  continuous  chromic 
catgut  number  00. 

246 


Fig.  383.  — Silk 
quilted  into  the  ten- 
don at  the  wrist  and 
then  tied  to  the  silk 
from  the  finger. 


MUSCLE  AND  TENDON  OPERATIONS 


247 


The  finger  and  wrist  are  immobilized  for  two  weeks,  after  that  slight 
motion  is  allowed  under  supervision  of  the  surgeon  for  three  weeks  more. 
After  that  the  splints  are  removed  and  the  muscles  trained. 

283.  Operation  to  give  Power  to  Supinate  the  Forearm  in  Cases 
of  Paralysis  of  the  Supinators. 
Tubby  Operation.  Transplanta- 
tion of  the  Pronator-radii-teres 
to  give  Power  of  Supina- 
tion.— The  transplantation  of  the 
pronator-radii-teres  is  done  for  a 
persistent  or  marked  tendency 
to  continuous  pronation  often 
present  in  spastic  cerebral  par- 
alysis and  sometimes  in  infantile 
paralysis  and  obstetrical  cases. 
Dr.  Tubby  advised  the  trans- 
plantation of  the  pronator-radii- 
teres  in  these  cases  converting 
the  muscle  into  a  supinator. 

An  esmark  and  tourniquet,  if 
used,  should  be  applied  carefully 
by  an  experienced  person.  The 
arm  is  bandaged  with  a  rubber 
bandage  from  the  finger  tips  to 
the  middle  of  the  upper  arm. 
Here  a  towel  is  applied  under  the  forearm  is  pronated 
tourniquet  which  should  be  ap-  the^upinXr?8  °f 
plied  with  great  care  and  not  too 
tightly.  As  soon  as  the  important  part  of  the  operation  is  over,  the 
tourniquet  should  be  removed  as  tourniquets  on  the  arm  are  undesirable 
for  any  length  of  time. 


Fig.  384.  —  Inci- 
sion for  transplanta- 
tion of  the  pronator- 
radii-teres  when  the 


Fig.  385.— Tis- 
sues and  superficial 
muscles  retracted  to 
show  the  oblique  fi- 
bers of  the  pronator- 
radii-teres. 


OPERATION    ON   THE   RIGHT  ARM 

The  operator  stands  on  the  outer  side  of  the  forearm  which  is  held 
supinated.  An  incision  is  made  (figure  384)  on  the  outer  third  of  the  fore- 
arm down  to  the  muscle  layer,  the  main  portion  of  the  muscular  fibers 
of  the  pronator-radii-teres  extend  across  the  arm  above  the  junction  of 
the  upper  and  middle  thirds  (see  figure  385).  The  tendinous  portion  is. 
largely  in  the  middle  portion  of  the  forearm.  To  find  the  muscle  easily, 
the  incision  should  be  made  in  the  outer  third  of  the  forearm  with  its 
middle  corresponding  to  the  junction  of  the  upper  and  middle  thirds. 
When  carried  down  to  the  muscle  layer,  the  incision  should  expose  the 
supinator  longus  (figures  386  to  388);  this  is  retracted  outward,  ex- 
posing the  pronator-radii-teres,  extending  obliquely  from  the  internal 
condyle  to  the  middle  of  the  radius.  It  is  the  only  oblique  muscle  here. 
If  the  operator  experiences  any  difficulty  in  finding  the  pronator-radii- 


248 


TECHNIQUE  OF  OPERATIONS 


teres,  he  may  expose  the  anterior  surface  of  the  radius.  If  he  traces 
this  upward,  he  will  come  across  the  oblique  attachment  of  the  pronator. 
In  dissecting  this  attachment  from  the  bone,  the  operator  should  work 
from  above  downward.  The  fibrinous  attachment  is  intimately  con- 
nected with  the  periosteum  which  is  very  much  coarsened;  in  dissecting 
the   insertion    subperiosteal^'    from    above   downward   it   is   possible 


Fig.  386.  —  Retrac- 
tors expose  the 
oblique  muscle  fibres 
of  the  pronator-radii- 
teres. 


Fig.  387.  —  Fur- 
ther retraction  ex- 
posing the  attach- 
ment of  the  prona- 
tor-radii-teres  along 
the  radius. 


Fig.  388. — Tendon  carrier  or 
clamp  passing  forward  to  grasp 
the  tendon  and  draw  it  out  of 
the  posterior  incision. 


to  obtain  a  very  much  longer  tendon 
which  will  reach  easily  around  the  radius 
(see  figures  389  to  394).  The  flexor  longus 
pollicis  and  sublimis  digitorum  lie  under 
the  pronator-radii-teres.  The  pronator  ten- 
don is  dissected  up,  a  blunt  dissector  is  used  to  separate  the  inter- 
osseous membrane  between  the  bones  close  to  the  radius. 

As  the  blunt  dissector  comes  to  the  surface  posteriorly,  a  small  incision 
is  made  over  it  allowing  it  to  protrude  through  the  skin.  A  long  clamp  or 
tendon  carrier  is  entered  here  and  protrudes  through  the  anterior  inci- 
sion passing  to  the  inner  side  of  the  radius.  It  grasps  the  tendon  of  the 
pronator  and  draws  it  out  posteriorly,  a  towel  is  placed  above  and 
another  below  the  muscle  while  silk  is  quilted  up  one  side  and  down  the 
other  of  the  tendon,  as  described  under  transplantation  of  the  peroneii. 
A  long  clamp  is  now  inserted  into  the  anterior  incision  extending  back- 
ward along  the  outer  side  of  the  radius.  It  protrudes  through  the  pos- 
terior incision,  grasps  the  silk  and  draws  it  forward  followed  by  the 


MUSCLE  AND  TENDON  OPERATIONS 


249 


tendon  on  the  outer  side  of  the  radius.  The  new  insertion  of  the  pronator- 
radii-teres  is  selected  slightly  above  its  previous  insertion.  The  bone  is 
drilled  here  (figure  390),  the  forearm  being  placed  in  a  position  one-half 
way  between  pronation  and  supination.  The  bone  is  drilled  antero- 
posteriorly  (see  figures  391,  392).  Two  ends  of  silkworm  gut  are  pulled 
through  this  drill  hole  to  be  used  as  a  leader  in  introducing  the  silk  from 
the  tendon.  The  loop  of  silkworm  gut  should  protrude  anteriorly  (see 
figure  394).  The  silk  from  the  tendon  is  drawn  through  (see  figure  394), 
and  protrudes  at  the  posterior  incision.  A  tendon  carrier  or  long  carrier 
is  passed  into  the  anterior  incision  to  the  inner  side  of  the  radii  and  pro- 
trudes from  the  posterior  incision.  The  silk  is  grasped 
by  it  and  pulled  forward.  One  end  is  passed  under  the 
silk  where  it  enters  the  drill  hole.     The  arm  should  be 


F  i  g.  3  8  9.— The 
pronator-radii -teres 
protrudes  backward 
and  is  then  drawn 
forward  to  the  outer 
side  of  the  radius. 


Fig.  390.  —  Diagram  of  the 
radius  and  ulna,  the  former 
being  pieced  by  a  drill.  A  silk 
wormgut  leader  is  being  passed 
through  the  drill  eye. 


Fig.  391.  — The 
silk  from  the  tendon 
extends  to  the  inner 
side  then  posterior 
and  enters  the  bone 
posteriorly  when 
the  arm  is  pro- 
nated. 


supinated  forcibly  before  tying  the  silk.  The  muscle  should  hold 
the  arm  in  a  supinated  position.  An  assistant  maintains  this  posi- 
tion while  the  muscle  is  drawn  tight  and  the  silk  tied  three  times. 
The  knot  is  pressed  flat.  The  subcutaneous  tissues  are  brought 
together  with  interrupted  chromic  catgut  sutures  number  00,  and 
the  skin  with  continuous  chromic  catgut  sutures  number  00.  A 
plaster  of  Paris  bandage  is  applied  (see  figure  395)  with  the  forearm 
held  in  a  supinated  position.  The  thumb  and  fingers  should  be  per- 
fectly free,  a  small  plaster  rope  being  applied  over  the  palm  of  the  hand 
which  is  well  padded.  The  plaster  should  be  split  on  both  sides  of  the 
arm  and  windows  cut  over  each  incision  to  allow  inspection  of  the  wound 
without  removing  the  apparatus.  If  there  is  much  swelling  the  plaster 
may  be  loosened  at  either  side  or  the  front  half  removed.    The  patient 


250 


TECHNIQUE  OF  OPERATIONS 


is  kept  in  bed  at  least  five  days.  Moving  about  increases  the  swelling. 
Where  the  surgeon  is  careful  and  gentle  in  the  manipulation  of  the  mus- 
cles and  subcutaneous  tissues,  the  swelling  will  be  correspondingly  less. 
The  wounds  should  be  dressed  on  the  fifth  and  seventh  days  with  gauze 
wet  with  alcohol.  After  that  the  wounds  are  dressed 
every  second  or  fourth  day  with  a  dry  dressing.  The 
supinated  position  of  the  forearm  should  be  main- 
tained from  four  to  six  months.  After  that  a  light 
apparatus,  such  as  a  plaster  or  leather  or  wire  splint 
(figure  401),  is  worn  maintaining  extreme  supination 


Fig.  892.— As  the 
arm  is  supinated  the 
silk  from  the  tendon 
enters  the  bone  from 
the  inner  side,  be- 
tween the  bones, 
and  is  tied  as  shown 
in  this,  and  the  next 
figure. 


Fig.  393.— R,  Radius. 
U,  Ulna.  When  the  fore- 
arm is  supinated  the  silk 
enters  the  bone  at  the 
inner  side  of  the  radius, 
protrudes  outward,  ex- 
tending posteriorly  and 
comes  up  to  the  inner 
side  where  it  is  tied. 


Fig.  394.— Prona- 
tor-radii-teres  held 
to  the  bone  by  silk. 


for  six  or  eight  hours  each  day.  Muscle  training  and 
daily  stretching  should  be  begun  after  the  sixth  week 
and  continued  for  a  year  at  least.  The  use  of  the 
extremely  supinated  position  daily  by  means  of  a 
splint  will  vary  according  to  the  control  of  the  arm 
and  the  tendency  to  pronate.  This  should  be  watched 
and  the  splint  used  accordingly. 

284.  Muscle  Transplantation  in  the  Forearm. — In  transplantation 
for  paralysis  of  the  extensors  of  the  wrist  and  fingers  the  different  methods 
are  given  below.  The  operator  will  have  to  select  the  muscles  spared  in 
the  individual  case.  A  gray  or  grayish  pink  muscle  will  not  be  suitable 
for  transplantation.  A  pinkish  red  should  not  be  selected  if  a  better 
one  is  available.  The  wrist  flexors  and  extensors  may  be  used  for 
paralysis  of  the  extensors  of  the  fingers  or  for  the  paralysis  of  the  flexors 
of  the  finger  as  described  below.  The  strong  muscles  must  often  be 
lengthened  or  stretched  out  before  it  is  safe  to  transplant.  This  must 
be  determined  by  the  individual  case. 

285.  Operation  for  Contracted  or  Short  Extensors  of  the  Wrist  and 
Fingers ;  Tendon  Lengthening. — The  patient  lies  on  his  back,  the  arm 
rests  on  a  table,  the  operator  stands  on  one  side,  the  assistant  on  the 
other. 

An  incision  is  made  three  or  four  inches  long  over  the  middle  third  of 


MUSCLE  AND  TENDON  OPERATIONS 


251 


the  forearm  down  to  the  muscles.  The  tendons  are  carefully  lifted  with 
a  blunt  dissector  to  assure  the  operator  of  the  exact  function  of  each  and 
to  which  finger  it  extends.     The  lengthening  should  be  done  in  the 


d 


Fig.  396.— The 
tendon  to  be  length- 
ened. 


Fig.  397.  — The 
tendon  cut  either 
straight  across  or  zig- 
zag (see  figure  399). 


Fig.  395. — Plaster  of  Paris  with 
the  elbow  straight,  the  forearm  supi- 
nated  and  a  long  piece  of  wood  incor- 
porated in  the  plaster  at  right  angles 
to  the  arm  extending  across  the 
patient's  lap  and  preventing  pronation 
of  the  arm. 

tendon  on  the  belly  of  the  mus- 
cle according  to  one  of  the 
methods  described  under  tendon 
lengthening.  (See  section  126). 
Each  tendon  should  be  noted 
previous  to  operation  and  the 
required  amount  of  shortening 
or  lengthening  estimated  for  each 
tendon.  At  the  time  of  opera- 
tion   the   surgeon    pulls  on   the 


Fig.  399.— Zig-zag 
tenotomy. 


tendon  and  recognizes  it  from  its  FlG-  398.  — Tendon 

,•  ,-,  •   ,  r  lengthened. 

action  on  the  wrist  or  finger. 
Each  one  is  lengthened  as  planned  before  operation  (see  figures  396  to 
399).  The  deep  tissues  are  brought  together  with  interrupted  chromic 
catgut  sutures  number  00,  the  subcutaneous  tissues  with  interrupted 
chromic  catgut  sutures  number  00,  the  skin  with  continuous  chromic  cat- 
gut sutures  number  00.    A  small  dressing,  four  or  five  layers  of  gauze, 


252 


TECHNIQUE  OF  OPERATIONS 


one  inch  wide  are  placed  on  the  wound  and  extending  one-half  inch  be- 
3Tond  the  incision  at  each  end.  Sterile  sheet  wadding  is  applied  over 
this.  A  wire  or  aluminum  splint  (see  figures  400  to  402)  or  plaster 
of  Paris  bandage  is  applied  holding  the  elbow  at  right  angles  and  the 
fingers  and  wrist  flexed  after  an  operation  on  the  extensors  and  hold- 
ing the  wrist  arid  fingers  extended  after  an  operation  on  the  flexors. 

In  cases  with  deformity  that  is  extreme  and  of  long  standing,  when  the 
flexors  are  lengthened  the  extensors  must  be  shortened  and  vice  versa. 


Fig.  400. —  Plaster  ap- 
plied allowing  the  use  of 
the  fingers,  or  extended 
holding  wrist  flexed  or  ex- 
tended with  the  elbow 
flexed  when  pronation  and 
supination  must  be  con- 
trolled. 


Fig.  401. — Plaster  of  Paris  bandage 
holding  the  wrist  and  fingers  flexed;  a 
similar  plaster  is  used  when  extension 
of  the  wrist  and  fingers  is  required. 


Fig.  402. — Aluminum  splint 
to  hold  the  wrist  and  fingers 
flexed.  A,  Elbow  portion  which 
is  strapped  on  with  tapes.  B, 
Forearm,  wrist  and  finger  por- 
tion holding  the  wrist  and  fin- 
gers flexed.  C,  Tape  which  is 
wound  between  the  finger  por- 
tion of  the  splint  and  over  the 
wrist  to  hold  the  splint  in  place. 
D,  End  view  of  the  finger 
portion  of  splint,  showing  the 
attachment  at  X  of  tape  C.  A 
splint  for  extension  of  the  fingers 
is  made  in  a  similar  way. 


The  operator  must  decide  on  the  value  of  the  muscles  and  act  accord- 
ingly. 

The  post-operative  treatment  is  the  same  as  that  laid  down  under  the 
transplantation  of  the  palmaris  longus. 

286.  Operation  for  Contracted  or  Short  Extensors  of  the  Wrist  and 
Fingers.  Lengthening  the  Muscles  by  a  Subperiosteal  Operation  at 
the  Condyle. — Contractures  of  the  fingers  and  wrist,  due  to  shortening 
of  the  long  extensors  of  the  wrist  and  the  fingers  should  be  overcome  by 
carefully  applied  splints.  When  the  deformity  is  extreme  this  is  not 
always  possible.  When  stretching  and  manipulation  have  been  per- 
formed in  a  careful  and  accurate  manner  over  a  considerable  period  of 
time,  additional  length  for  the  extensor  tendon  may  be  obtained  by 


MUSCLE  AND  TENDON  OPERATIONS 


253 


loosening  the  attachment  of  these  muscles  at  the  elbow.     This  opera- 
tion is  very  satisfactory  when  the  tendons  are  evenly  contracted. 


OPERATION   AT   THE    CONDYLE 

The  patient  lies  on  his  back,  the  arm  is  laid  across  the  thorax.  The 
operator  stands  on  the  same  side  of  the  operating  table  as  the  arm  to  be 
operated  on.  When  the  exten- 
sors are  contracted,  an  incision 
two  and  one-half  inches  long  is 
made  over  the  outer  condyle  of 
the  arm  down  to  the  bone.  The 
muscles  are  detached  subperios- 
teally  from  the  external  condyle 
by  means  of  a  small  osteo- 
tome; the  detached  muscles  are 
pushed  downward  until  the  fin- 
gers can  be  completely  flexed. 

Post-operative  treatment 

An  apparatus  should  be  worn 
after  the  operation  continuously 
for  eight  weeks  and  for  part  of 
each  day  after  that,  depending 
on  the  tendency  of  the  muscles  tions"tobe  removed 
to  recontract.  are  here  shaded. 


Fig.  403.  —  Ten- 
don shortening,  por- 


Fig.  404.— Suture  of 
shortened  tendons. 


Operation  on  the  belly  of  the  muscle  for  lengthening  the  long  extensors  of  the 

wrist  and  fingers 

An  incision  is  sometimes  made  over  the  contracted  muscles  and  a  few 
fibers  cut  at  different  points  in  the  belly  of  the  muscle  to  allow  it  to 
stretch  down.  The  tendons  may  be  cut  and  lengthened  in  the  belly 
of  the  muscle  (figures  396  to  398).  Lengthening  at  the  condyle  or  in  the 
tendon  over  the  muscles  are  the  better  procedures. 

Post-operative  treatment 

Extreme  overcorrection  should  be  maintained  at  the  time  of  opera- 
tion. It  is  often  necessary  to  manipulate  the  finger  and  wrist  joint 
after  a  deformity  of  long  standing.  Each  joint  should  be  carefully 
manipulated.  Contracted  fibers  will  yield  with  very  little  reaction  to 
gradual  force  frequently  relaxed.  The  relaxing  of  force  and  repeated 
stretching  should  be  done  without  roughness  until  the  joint  yields. 
Weak  muscles  cannot  be  expected  to  gain  until  their  strong  opponents 
and  the  tissues  limiting  motion  are  all  overstretched.  At  times  in  addi- 
tion to  lengthening  the  extensors  it  is  necessary  to  shorten  the  flexors  as 
described  elsewhere  in  these  pages. 


254  TECHNIQUE  OF  OPERATIONS 

287.  Operation  for  Contracted  Flexors  of  the  Wrist  and  Fingers. 
Tendon  Lengthening. — The  incision  is  made  over  the  flexors  and  the 
tendons  lengthened  as  described  for  lengthening  the  contracted  tendons 
of  the  exi  elisors  (figures  396  to  398). 

288.  Operation  for  Contracted  Flexors  of  the  Wrist  and  Fingers, 
Lengthening  the  Muscles  by  a  Subperiosteal  Operation  at  the  Con- 
dyle.— This  operation  is  done  at  the  internal  condyle  in  a  similar  way 
to  that  described  for  contracted  extensors  of  the  forearm  performed  at 
the  external  condjde.    See  section  386. 

After  operation  the  elbow  is  held  at  right  angles,  the  wrist  and  fingers 
are  put  up  in  a  position  of  extreme  extension.  Otherwise  the  post- 
operative treatment  is  the  same  as  that  for  contracted  extensors. 

It  is  sometimes  necessary  to  shorten  the  extensors  as  well  as  to 
lengthen  the  flexors.  The  operator  should  see  that  the  finger,  wrist 
and  elbow  joints  will  bend  normally  to  allow  use  after  correcting  the 
condition. 

289.  Operation  for  Shortening  the  Long  Flexors  of  the  Wrist  and 
Fingers.  Muscle  and  Tendon  Shortening. — The  patient  lies  on  his 
back,  the  arm  rests  on  a  table.  In  operation  on  the  right  arm,  the  opera- 
tor stands  facing  the  external  condyle  of  the  humerus.  The  assistant 
stands  between  the  body  and  the  arm.  For  the  left  forearm,  the  posi- 
tions are  reversed. 

OPEEATION 

A  longitudinal  incision  three  inches  long  is  made  over  the  middle  of 
the  forearm  at  the  junction  of  the  middle  and  lower  third.  It  should 
extend  through  the  skin  and  fat  which  are  dissected  up  in  one 
layer. 

When  the  tendons  are  reached,  any  one  of  the  methods  described 
under  tendon  shortening  may  be  used.  Each  tendon  should  be  noted 
previous  to  operation  and  the  required  amount  of  shortening  or  lengthen- 
ing estimated  for  each  tendon.  At  the  time  of  operation,  the  surgeon 
pulls  on  the  tendon  and  recognizes  it  from  its  action  on  the  wrist  or 
finger.  Each  one  is  shortened  as  planned  before  operation.  The 
shortening  is  done  either  in  the  tendon  overlying  the  muscle  or  below 
the  muscle  (figures  403,  404) .  When  the  operation  is  completed  a  small 
piece  of  gauze  four  or  five  layers  thick  is  placed  over  the  wound,  extend- 
ing a  half  inch  beyond  at  either  end  and  one  inch  broad.  Sterile  sheet 
wadding  is  placed  over  this  and  the  arm  and  hand  are  held  flexed  by  a 
wire  or  aluminum  splint  holding  the  wrist  flexed,  or  a  plaster  of  Paris 
dressing.  The  front  half  of  the  plaster  may  be  removed.  A  gauze  bandage 
is  then  applied  after  removing  the  front  half  of  the  plaster.  This  opera- 
tion is  recommended  when  the  opposing  muscles  have  stretched  out  the 
flexors.  To  assure  a  permanent  result  the  strong  extensors  should  be 
stretched  out  daily.  In  extreme  cases,  the  extensors  should  be  length- 
ened at  the  time  of  operation  (figures  396  to  398). 


MUSCLE  AND  TENDON  OPERATIONS  255 

After  treatment 

A  splint  is  worn  constantly  for  two  months  after  the  operation. 
After  that  the  splint  is  removed  more  and  more;  finally  being  used  only 
two  hours  daily  for  one  or  two  years,  depending  on  the  tendency  of 
the  deformity  to  recur.  Exercises  and  muscle  training  should  be  light 
at  first  and  continued  at  least  as  long  as  the  splint  is  thought  necessary. 
In  most  cases  the  arm  should  be  exercised  for  several  years  after  the 
splint  is  discarded. 

290.  Operation  for  Shortening  the  Long  Extensor  Tendons  of  the 
Wrist  and  Fingers.  Muscle  and  Tendon  Shortening. — The  patient 
lies  on  his  back,  an  assistant  holds  the  flexed  elbow  on  a  table,  the  opera- 
tor sits  facing  the  posterior  surface  of  the  forearm  and  makes  an  incision 
three  inches  long  in  the  lower  half  through  the  skin  and  fat  exposing  the 
tendons.  The  tendons  may  be  shortened  in  the  muscle  or  below  it  (see 
Tendon  Shortening). 

The  detail  of  the  operation  of  tendon  shortening  is  now  similar  to  that 
described  for  shortening  the  long  flexors  of  the  fingers.  (Section  289.) 
Each  tendon  should  be  noted  previous  to  operation  and  the  required 
amount  of  shortening  or  lengthening  estimated  for  each  tendon.  At 
the  time  of  operation  the  surgeon  pulls  on  the  tendon  and  recognizes 
it  from  its  action  on  the  wrist  and  finger.  Each  one  is  shortened  as 
planned  before  operation. 

Post-operative  treatment 

After  the  operation  a  plaster  or  wire  or  an  aluminum  splint  is  applied, 
holding  the  elbow  at  right  angles  and  the  wrist  and  fingers  fully  ex- 
tended. In  extreme  cases  it  may  be  necessary  to  lengthen  the  flexors. 
The  success  of  the  operation  depends  on  the  same  treatment  and  after 
care  laid  down  for  the  post-operative  care  in  shortening  the  flexor  ten- 
dons of  the  forearm. 

291.  Operation  for  Paralysis  of  the  Extensor  Longus  Pollicis  or 
Extensor  Longus  Digitorum.  Transplantation  of  the  Palmaris  Longus. 
—Where  the  extensors  of  the  fingers  are  paralyzed  the  palmaris  longus  is 
exposed  by  an  anterior  incision,  its  tendon  freed  below;  the  muscle 
dissected  up  to  the  middle  of  the  forearm  where  a  blunt  dissector  is 
used  to  separate  the  muscles,  and  the  interosseous  membrane.  As  the 
blunt  dissector  is  made  to  protrude  posteriorly,  an  incision  is  made 
through  the  skin  over  it,  a  tendon  carrier  or  long  clamp  is  passed  for- 
ward from  the  posterior  to  the  anterior  incision  and  the  tendon  grasped 
and  drawn  out  posteriorly.  A  towel  is  placed  above  and  another  below 
the  tendon,  while  silk  is  quilted  up  one  side  and  down  the  other.  The 
posterior  incision  is  extended  downward  and  the  paralyzed  tendons  ex- 
posed, the  surgeon  pulling  on  each  one  to  assure  himself  to  which 
joints  they  go.  The  tendon  of  the  palmaris  is  attached  by  its  silk, 
quilted  into  the  extensor  tendons  on  the  back  of  the  forearm,  with  or 


256 


TECHNIQUE  OF  OPERATIONS 


without  passing  it  through  a  slit  in  the  paralyzed  extensors;  these  are  all 
quilted  with  the  silk  from  the  palmaris  tendon.  (See  figures  408,  409). 
The  muscle  transplanted  should  hold  the  fingers  slightly  extended. 
The  method  of  applying  the  silk  is  described  under  transplantation  of 
the  peroneii.     Section  148. 


After  treatment 

After  operation,  a  wire  or  aluminum  splint  or  plaster  is  worn  stretch- 
ing out  the  strong  muscles  and  relaxing  the  transplanted  and  weak 
muscles.  The  splint  should  immobilize  the 
elbow,  wrist  and  fingers  for  three  weeks.  After 
that  finger  motions  are  encouraged  each  day. 
The  splint  is  worn  for  six  weeks  and  omitted  a 
little  at  a  time.  After  that  muscle  training  and 
exercise  are  started  before  the  eighth  week. 

The  splint  is  gradually  omitted  except  for  two 
to  four  hours  a  day,  depending  on  the  tendency 
of  the  strong  muscles  to  recontract.  The  rules 
for  lengthening  tendons  and  muscles  are  given 
elsewhere  in  these  pages,  should  it  be  necessary 
to  readjust  other  tendons  in  addition  to  trans- 
planting. 

292.  Other  Transplantations  in  the  Forearm, 
for  Paralysis  of  the  Extensor  Longus  Digitorum 
or  the  Extensor  Longus  Pollicis. — At  the  wrist, 
the  flexor  carpi  ulnaris  and  the  flexor  carpi 
radialis,  the  palmaris  longus  and  in  some  cases 
the  extensor  carpi  radialis,  when  spared,  may  be 
transplanted  to  take  the  place  of  the  extensors 
of  the  fingers  or  thumb  in  a  manner  already  de- 
scribed for  the  transplantation  of  the  palmaris 
longus. 

293.  Transplantations  in  the  Forearm  for 
Paralysis  of  the  Flexor  Longus  Digitorum  and 
Flexor  Longus  Pollicis. — In  paralysis  of  the 
flexor  longus  digitorum  and  flexor  longus  pollicis, 
the  extensor  carpi  ulnaris,  or  the  extensor  carpi 

radialis  and  the  flexor  carpi  ulnaris  one  or  two  may  be  brought  forward 
and  inserted  into  the  flexors  of  the  fingers  or  thumb  as  described  for  the 
transplantation  of  the  palmaris  longus  backward. 

294.  Operation  for  Paralysis  of  the  Flexor  Longus  Pollicis  when  the 
Flexor  Carpi  Radialis  is  Spared. — The  flexor  carpi  radialis  may  be 
used  (see  figures  405  to  407)  for  paralysis  of  the  flexor  longus  pollicis 
and  transplanted  as  described  for  transplantation  of  the  palmaris 
longus. 


Fig.  405.  —  Incision  for 
paralysis  of  the  flexor 
longus  pollicis  when  the 
flexor  carpi  radialis  is 
spared.      A,  Median  nerve. 

B,  Flexor     carpi    radialis. 

C,  Flexor  longus  pollicis. 


MUSCLE  AND  TENDON  OPERATIONS 


257 


295.  Operation  for  Paralysis  of  the  Flexors  of  the  Wrist,  Trans- 
plantation of  the  Extensor  Carpi  Radialis  and  the  Flexor  Carpi  Ulnaris. 
—The  extensor  carpi  ulnaris  or  extensor  carpi  radialis  may  be  trans- 
planted forward  as  described  for  the  palmaris  longus  when  transplanted 
backward. 

296.  Nerve  Supply  in  the  Forearm. — As  an  additional  guide  in 
paralytic  cases  the  following  summary  of  the  nerve  supply  may  be  of 


Fig.  406.— B,  The  flexor  carpi 
radialis  is  split  and  retracted. 
C,  The  flexor  longus  pollicis  is 
cut  away  and  its  distal  end 
quilted  with  silk. 


Fig.  407.  — The  flexor 
longus  pollicis  (C)  is 
passed  through  the  flexor 
carpi  radialis.  Quilted 
sutures  unite  the  tendons. 
The  flexor  carpi  radialis 
is  cut  across  to  allow  free 
action  of  the  thumb. 


Fig.  408. —Silk 
tendon  elongation  to 
replace  a  cut  or  ad- 
herent tendon.  The 
needle  should  pierce 
the  tendon  at  right 
angles  in  applying 
the  silk. 


help.  The  operator  should  get  a  strong  voluntary  reaction  in  any  muscle 
he  intends  to  transplant.  Without  good  control  the  muscle  will  be  of 
little  value.  Sometimes  it  is  necessary  to  train  the  muscles  to  the 
proper  strength.  At  the  time  of  operation  the  muscle  to  be  trans- 
planted, to  be  satisfactory,  should  be  a  good  red  color  even  when  a 
tourniquet  is  applied. 

The  pronator  and  flexor  muscles  of  the  forearm  receive  their  nerves 
mostly  from  the  median,  only  one,  the  flexor  carpi  ulnaris,  being  wholly 
and  another,  the  flexor  profundus  digitorum,  in  part  supplied  from  the 
ulnar  nerve  by  branches  entering  them  near  the  elbow.  The  pronator 
radii  teres,  flexor  carpi  radialis,  palmaris  longus,  and  the  condylo-ulnar 


258 


TECHNIQUE  OF  OPERATIONS 


Fig.    409. 


Silk 

applied    to    the   ten-    anatomy), 
don. 


head  of  the  flexor  sublimis  digitorum  receive  branches 
from  the  median  in  the  neighborhood  of  the  elbow, 
while  the  radial  head  and  the  index  finger  belly  of 
the  flexor  sublimis  have  separate  twigs  from  the 
same  trunk.  The  flexor  longus  pollicis,  pronator 
quadratus  and  outer  half  of  the  flexor  profundis  digi- 
torum are  supplied  by  the  anterior  interosseous 
branch  of  the  median.  The  outer  two  lumbricales 
are  innervated  by  the  median  and  the  inner  two  by 
the  ulnar  (Quain's  anatomy). 

The  anconeus,  supinator  longus  and  extensor  carpi 
radialis  longior  receive  branches  from  the  musculo- 
spiral  nerve,  the  remaining  muscles  of  this  group  are 
supplied  by  the  posterior  interosseous  division  of 
that  trunk,  the  offsets  for  the  extensor  carpi  radialis 
brevior  and  supinator  brevis  arising  from  the  nerve 
before  it  pierces  the  matter  muscle,  while  those,  for 
the  extensors  of  the  digits,  both  superficial  and  deep 
as  well  as  the  extensor  carpi  ulnaris  are  given  off 
after  it  appears  on  the  back  of  the  forearm  (Quain's 


CHAPTER  III 

INCISION   PUNCTURE   AND   ARTHROTOMY 

297.  Arthrotomy  at  the  Wrist. — A  knowledge  of  the  important 
routes  of  approach  to  the  joints  will  facilitate  any  joint  exploration,  the 
removal  of  foreign  bodies,  the  repair  of  traumatic  conditions,  the  ad- 
justment of  difficult  fractures,  the  reduction  of  old  and  difficult  disloca- 
tions, the  mobilization  of  joints  where  motion  is  partially  or  totally  lost, 
and  the  stiffening  of  the  joint  as  in  certain  paralytic  conditions,  the 
treatment  and  drainage  of  suppurative  conditions;  a  knowledge  of  the 
important  routes  of  approach  to  the  joint  is  very  important.  For  each 
case,  the  operator  will  select  the  incision  best  suited  for  the  individual 
condition.     Each  joint  will  be  considered  separately  in  other  chapters. 

The  incision  should  be  made  down  to  the  synovial  cavity.  All  bleed- 
ing should  be  stopped  and  the  synovial  membrane  carefully  opened. 
The  joint  structures  should  be  tampered  with  as  little  as  possible,  the 
synovial  membrane  brought  together  carefully  and  the  layers  over  it 
closed  in  order  not  to  disturb  the  function  of  the  periarticular  tissues. 
Unnecessary  separation  of  the  tissue  layers  is  to  be  avoided.  Tendons 
should  be  left  in  their  sheath.  Any  ligaments  that  must  be  cut  should 
be  loosened  periosteally,  in  order  that  they  may  be  readily  replaced. 
Early  motion  should  be  the  rule,  gentle  at  first,  and  gradually  increased. 

Arthrotomy  at  the  wrist  is  done  for  deformity,  congenital  or  acquired, 
compound  fractures,  ankylosis  following  injury  or  disease  and  suppura- 
tive conditions.  Joint  operations  should  never  be  hastily  considered 
and  should  be  avoided  by  anyone  not  familiar  with  the  best  surgical 
technique. 

When  it  is  necessary  to  have  free  access  to  the  bones  on  account  of 
fracture,  deformity  or  suppurative  disease,  less  injury  is  done  to  the 
soft  parts  if  the  operator  will  use  an  anterior  and  a  posterior  incision  at 
the  same  time  rather  than  a  single  incision.  It  must  be  remembered 
that  any  operation  at  the  wrist  may  involve  serious  injury  or  adhesion 
or  even  sloughing  of  the  tendons  which  later  may  interfere  seriously 
with  the  action  of  the  fingers.  This  can  be  avoided  by  sufficiently  long- 
incisions  to  allow  easy  retraction  of  the  tendons  undisturbed  in  their 
sheath  with  the  underlying  periosteum  still  attached.  The  posterior 
annular  ligament  must  be  incised.  With  one  finger  through  the  an- 
terior and  another  through  the  posterior  incision  it  is  possible  to  manipu- 
late or  remove  the  bones  without  roughness  and  trauma.  The  amount 
of  swelling,  pain  and  injury  from  the  operation  will  be  correspondingly 
less. 

For  exploratory  operation  on  the  wrist,  the  anterior  or  the  posterior 

259 


260 


TECHNIQUE  OF  OPERATIONS 


incision  may  be  used,  or  both.  The  posterior  is  preferable  where  only 
one  is  to  be  used.  It  extends  from  between  the  styloids  to  the  second 
or  third  metacarpal. 

For  purposes  of  drainage,  an  anterior  and  posterior  incision  should 
be  made  and  sometimes  a  radial  or  lateral,  depending  on  the  extent  of 
the  disease  or  injury.     An  x-ray  will  help  determine. 

For  simple  irreducible  fractures,  compound  fractures,  dislocation  or 
internal  displacement  demanding  operative  intervention,  the  anterior 
and  posterior  incisions  should  be  used  unless  one  is  sufficient,  but  for 
suppuration  at  the  wrist  two  or  more  incisions  are  necessary. 

When  removal  of  one  or  more  bones  is  necessary  as  in  tuberculosis,  a 
better  result  as  to  function  is  obtained  when  all  the  bones  are  removed 
with  perhaps  the  exception  of  the  pisiform  and  perhaps  the  trapezius, 
the  unciform  process  of  the  unciform  may  be  left.  Even  when  only  one 
bone  is  diseased  there  is  less  danger  of  stiffness  by  a  complete  excision. 
There  is  never  abnormal  mobility  if  the  operation  is  done  subperiosteal^ 
even  though  all  the  carpal  bones  are  removed. 

298.  Arthrotomy  at  the  Wrist.  Ollier's  Incisions. — Oilier  advises 
three  incisions  for  suppurative  conditions,  an  anterior  lateral,  a  posterior 
and  a  small  external  for  drainage  when  necessary. 

The  arm  is  evasculated  by  an  esmark  and  tourniquet  (the  tourniquet 
is  applied  over  a  towel  for  a  short  time  only).  The  skin  having  been 
carefully  prepared  and  the  field  of  operation 
protected,  the  arm  rests  on  a  small  table  to  one 
side  of  the  operating  table.  The  operator  sits 
facing  the  side  of  the  table,  his  assistant  faces 
him.  The  arm  is  pronated  and  rests  on  a  sand 
bag. 

299.  Posterior  Incision. — An  incision  is 
made  midway  between  the  styloids  starting 
one  inch  above  them  and  extending  vertically 
downward  through  the  posterior  annular  liga- 
ment to  the  middle  of  the  second  metatarsal 
along  the  outer  side  of  the  extensor  indicis. 
The  dissection  is  carried  down  to  the  perios- 
Starting0S  onT  inch  teum,  the  extensor  indicis  is  to  be  retracted 
inward  and  the  extensor  secondi  internodii  out- 
ward. The  extensor  carpi  radialis  longus  and 
brevis  should  be  spared  and  detached  sub- 
tensor  indicis  to  the  middle  periosteally  (see  figure  410). 
of  the  second  metacarpal.  300    Arthrotomy   of   the   Wrist.      Anterior 

Incision. — A  palmar  incision  is  made  over  the  radial  border  of  the 
ulna  starting  one  inch  above  the  styloid  process  and  extending  to 
the  base  of  the  fifth  metacarpal,  leaving  the  flexor  carpi  ulnaris  to 
the  inner  side.  This  incision  is  carried  down  to  the  periosteum  (fig- 
ure 411). 


sion.  starting  one 
above  the  styloids  and  pass- 
ing through  the  middle  of  a 
line  connecting  them  along 
the  outer  border  of  the  ex- 


INCISION,  PUNCTURE  AND  ARTHROTOMY 


261 


301.  Radial  Incision. — A  third  incision  is  now  made  when  necessary 
(see  figure  411),  one  inch  long  over  the  styloid  process  of  the  radius;  it 
is  carried  down  to  the  bone  and  made  before 
removing  the  carpus.  For  complete  drainage, 
for  tuberculous  or  purulent  disease,  three  inci- 
sions are  made.  The  operation  is  continued 
as  the  case  requires. 

For  adjustment  of  fractures,  correction  of 
deformity  or  excision,  where  there  is  no  active 
disease  the  posterior  and  anterior  are  all  that 
are  necessary. 

302.  Arthrotomy  at  the  Metacarpal  and 
Phalangeal  Joints.  Operations  on  the  Long 
Bones  of  the  Finger  and  Hand. — The  finger 
joints  are  best  reached  by  one  or  two  dorsal 
incisions  between  the  tendon  and  the  artery. 
When  necessary  a  palmar  incision  similarly 


Fig.  411. — Anterior  incision. 
Starting  one  inch  above  the 
styloid  along  the  radial  border 
of  the  ulna  to  the  base  of  the 

situated  is  made,  but  m  view  of  the  tendency  mh   meUearpal  '  the   nex0r 

to  SCar  contracture  it  is  better  to  have  the  in-    carpi  ulnaris  to  the  inner  side. 

Cision    on     the    dorsum.        (See     figures     412,    Tne.radi.al  or  external  lateral 

incision  is  made  over  the  sty- 
41o.)  loid  of  the  radius  for  one  or 

The  incision  is  made  with  a  scalpel  down  one  and  one-half  inches. 
to  the  bone  through  the  periosteum.  A  long  handled  small  osteotome 
is  then  used  to  raise  the  periosteum  exposing  the  joint  and  the  bone, 
above  and  below,  without  disturbing  the  structures  between  the  perios- 
teum and  the  skin.  Hooks  or  small  retractors  are  used,  exposing  the 
bone  or  joint.  When  the  joint  is  subluxated,  the  ligaments  may  be 
relieved  subperiosteally  and  the  joint  replaced.  In  some  instances  it  is 
necessary  to  excise  a  portion  of  the  bone  as  described  for  hammer  toe. 
The  long  bones  of  the  hand  and  finger  are  reached 
in  the  same  way. 

303.  Arthrotomy  for  Fractures  about  the  Joints. 
— The  necessity  of  immediate  operation  in  fractures 
about  the  joints  depends,  as  in  other  fractures,  on 
the  acuteness  of  the  local  and  general  reaction. 
When  these  do  not  contra  indicate  immediate  opera- 
tion, certain  fractures  about  the  joints  may  require 
treatment  by  the  open  method.    Among  these  are 

Fig.  412. — Incision      ,,  j  »        ,  ,  , ,  ,  ~     .    ,      , 

for  arthrotomy  at  the  a^  compound  fractures,  even  when  the  protrusion  of 
metacarpophalangeal  the  bone  has  been  extremely  slight,  all  fractures 
Jolnt*  that  cannot  be  reduced  by  manipulation  or  in  which 

the  correction  cannot  be  maintained  or  Avhere  apposition  is  impossible, 
many  fractures  combined  with  dislocation,  articular  fractures  with 
pieces  locking  or  limiting  the  joint  action. 

Where  there  is  a  great  deal  of  trauma,  and  in  multiple  fractures,  and 
in  cases  where  there  is  a  great  deal  of  shock,  all  that  can  be  done  is  to 


202  TECHNIQUE  OF  OPERATIONS 

immobilize  the  parts  until  a  favorable  time  for  operation.  In  selecting  a 
suitable  time  for  operation  when  it  is  found  necessary  to  operate  on  a 
fracture  it'  there  is  no  immediate  contra  indication,  the  sooner  it  is  done 
the  better.  Where  there  is  tremendous  swelling  the  surgeon  should 
always  wait.  All  cases  should  be  operated  on  that 
show  no  union  after  three  months  of  good  treat- 
ment. 

Methods  of  treating  the  individual  fracture  cannot 
be  considered  in  a  limited  space  like  this.  The  writer 
has  described  the  routes  of  approach  to  the  different 
joints  and  the  technique  of  these.  This  will  enable 
the  surgeon  from  his  knowledge  of  fractures  to  select 
Fiq.  413.  —  inci-  ^ne  route  best  adapted  for  the  individual  treatment 
sion  for  arthrotomy,  required  and  when  necessary  two  or  more  incisions 
phalangeal  jomt.  may  ^e  use(j#  a  knowledge  of  the  technique  will 
enable  the  surgeon  to  work  rapidly  in  reaching  the  fracture  on  which 
he  expects  to  spend  time. 

304.  Fractures  of  Long  Standing  Still  Ununited  or  United  with 
Deformity,  Preventing  Function.  Fractures  near  or  of  the  Carpus. — 
Deformity  from  fractures  at  the  wrist  may  be  corrected  by  an  osteotomy 
of  one  or  both  bones  as  the  case  requires.  An  incision  is  made  as  for  exci- 
sion of  the  wrist  or  at  the  side  separately  for  each  bone.  The  bones  are 
cut  through  by  means  of  an  osteotome,  and  the  case  treated  as  if  it  were 
a  fresh  fracture  by  well  fitting  anterior  and  posterior  splints.  When 
there  is  deformity  low  down  and  the  fracture  is  under  three  weeks  old, 
it  is  usually  possible  to  manipulate  the  fracture,  and  correct  the  deform- 
ity without  an  open  incision.  The  treatment  of  fracture  of  both  bones 
by  the  open  method  is  described  elsewhere  in  these  pages.  The  Thomas 
wrench  as  described  in  these  pages,  may  be  used  to  manipulate  the  wrist. 
This  has  been  suggested  by  Dr.  Stone.*  Separation  of  the  epiphysis 
with  deformity  may  be  corrected  by  means  of  a  Thomas  wrench,  if  the 
fracture  is  three  weeks  old.  Occasionally  it  is  possible  to  correct  frac- 
tures, when  they  are  five  weeks  old,  when  the  union  is  soft.  The  surgeon 
should  be  careful  to  avoid  trauma  in  manipulating  the  fracture.  It  is  bet- 
ter to  cut  the  bone  with  an  osteotome  and  avoid  trauma,  than  to  manipu- 
late to  such  an  extent,  with  force,  as  to  cause  a  great  deal  of  swelling. 

In  injury  of  the  carpus,  the  bone  most  commonly  fractured  is  the  sca- 
phoid. The  semiluna  may  be  displaced  with  or  without  fractures  of  the 
scaphoid.  In  fractures  of  the  scaphoid,  the  fracture  heals  without 
giving  any  trouble. 

Occasionally  there  is  displacement  of  one  of  these  bones  or  of 
a  fragment.  Where  there  is  displacement,  sometimes  it  is  impos- 
sible to  manipulate  the  fragment  into  position.  When  this  is  the 
case,  an  incision  is  made  and  the  displaced  fragment  removed.  Oc- 
casionally the  whole  bone  should  be  removed.  An  excellent  result 
*  Dr.  J.  S.  Stone,  Boston. 


INCISION,  PUNCTURE  AND  ARTHROTOMY  263 

follows  the  operation.  Fracture  of  the  scaphoid  will  limit  motion  in 
extension  of  the  wrist  without  limiting  flexion  to  any  great  extent. 
Displacement  of  the  semilunar  bone  may  require  removal  of  this  hone 
to  obtain  good  function  of  the  wrist,  when  after  long  immobilization 
function  is  still  impaired. 

In  any  case  where  there  has  been  infection,  no  plastic  operation  should 
be  used  until  the  infection  has  been  entirely  absent  for  at  least  nine 
months.  A  year  is  safer.  Where  the  infection  is  very  mild  and  of 
long  standing,  during  the  process  of  treatment  the  patient  may  be 
allowed  to  use  the  arm  if  the  local  reaction  is  not  too  great.  It  is  of  ad- 
vantage in  certain  cases  to  use  a  wire  or  leather  splint  to  take  some  of 
the  strain.  Where  the  x-ray  shows  conical  ends  of  the  bone  it  is  practi- 
cally useless  to  expect  union  without  surgical  interference. 

305.  Tapping  the  Wrist  Joint. — The  most  scrupulous  aseptic  pre- 
cautions are  necessary  both  as  to  the  preparation  and  the  protection  of 
the  field  of  the  operation. 

The  forearm  is  pronated  and  the  joint  tapped  at  the  styloid  process 
of  the  ulna  between  it  and  the  long  extensor  tendons,  or  at  the  level  of 
the  styloid  of  the  radius  between  the  extensor  longus  indicis  and  extensor 
longus  pollicis.    The  tapping  may  be  done  under  local  anaesthesia. 

When  there  is  much  effusion  it  is  not  difficult  to  reach  the  joint. 
If  fluid  is  to  be  drawn,  and  other  solutions  are  to  replace  it,  the 
amounts  should  be  carefully  measured.  Two  good  graduated  metal 
syringes  are  very  useful.  All  of  their  parts  should  be  tested  before- 
hand. The  trocar  is  made  to  enter  the  joint  and  then  is  connected 
with  the  syringe.  As  little  air  as  possible  should  enter  the  joint. 
The  trocar  should  be  of  large  diameter  as  the  fluid  may  be  thick 
or  flaky.  When  the  patient  is  not  anaesthetized  for  the  operation 
it  is  often  well  to  have  a  short  flexible  tube  connect  the  trocar  with 
the  syringe.  This  should  be  fastened  at  both  ends  by  silk  ties  so  that  it 
will  not  leak  easily  when  pressure  or  suction  is  used.  If  the  joint  is  to 
be  washed  out  a  definite  amount  of  fluid  is  injected  and  the  return  meas- 
ured in  a  sterilized  measuring  glass. 

Dr.  Murphy  uses  a  formalin  glycerine  solution  as  follows:  liquor  for- 
maldehyde 2%  in  glycerine,  about  ten  drops  of  the  formaldehyde  to 
each  ounce  of  glycerine. 

This  acts  very  well  in  infectious  synovitis.  But  it  should  not  be  used 
in  arthritis  deformans  nor  in  old  chronic  arthritis. 

The  tapping  may  be  done  with  ethyl  chlorid  or  novocaine  adreneline 
solution,  1%.  The  solution  should  be  prepared  twenty-four  hours  before 
it  is  used  (Murphy). 


CHAPTER  IV 

OPERATIVE   TREATMENT   IN   CASES   OF   JOINT  ANKYLOSIS 

306.  Arthroplasty. — Ankylosis  may  be  bony,  cartilaginous  or 
fibrinous,  it  may  be  periarticular,  ligamentous  and  capsular,  or  extra 
articular,  that  is,  skin  scars,  tendons,  fascia,  nerves  and  arteries. 

The  form  of  ankylosis  that  exists  will  determine  the  treatment.  A 
partial  ankylosis  at  certain  points  had  better  not  be  treated  by  an 
arthroplasty. 

Age  must  be  considered,  also  the  general  condition  of  the  patient. 
When  the  ankylosis  is  bony,  cartilaginous  or  fibrinous,  arthroplasty  is 
indicated.  When  the  condition  is  periarticular  or  extra  articular,  it  may 
be  treated  by  capsulotomy,  tendon  elongation,  excision  of  exostosies,  etc. 

Dr.  Murphy  lays  stress  on  the  following  points: — The  principles  of 
asepsis  to  the  finest  detail  are  absolutely  essential.  One  not  familiar 
with  the  best  surgical  technique  should  avoid  arthroplasty  operations. 
The  exposure  of  the  joint  must  be  generous  and  complete.  The  con- 
tracted capsular  ligaments  and  soft  parts  must  be  freed  and  if  necessary 
lengthened.  The  normal  contour  of  the  joint  should  be  restored  as  nearly 
as  possible.  The  operator  should  obtain  a  hyper-mobilization  of  the 
joint.  The  joint  should  be  reshaped  to  give  stability.  The  inter- 
position of  material  to  prevent  reunion  of  the  bone  is  necessary. 

The  principle  is  to  separate  the  bones  and  to  interpose  between  them 
material  to  prevent  ankylosis.  The  best  material  for  this  purpose  is 
the  human  pedicle  composed  of  fat,  muscle,  fascia  or  a  combination  of 
these. 

When  this  is  not  possible,  a  transplantation  is  made  of  fat  and  fascia 
from  the  trochanter  bursa  region  or  from  the  fascia  lata. 

Materials  such  as  ivory,  celluloid,  silver  are  not  good.  Materials  that 
will  not  absorb  or  that  absorb  too  slowly  are  not  desirable. 

During  the  operation  the  soft  parts  should  be  freely  liberated.  Attach 
the  interposing  flap  to  one  bone  only  and  cover  it  completely.  Early 
motion,  that  is,  at  the  end  of  five  to  seven  days  is  necessary  with  or 
without  gas  or  gas  and  oxygen. 

Dr.  Murphy  records  failures  in  arthroplasty  as  due  to  first,  insufficient 
and  defective  exsection  of  the  capsule  and  ligaments,  second,  insufficient 
interposition  of  fat  and  fascia  between  the  separated  bony  surfaces, 
third,  infection,  fourth,  the  sensitiveness  to  pain  on  motion  after  opera- 
tion. 

Cases  of  primary  tuberculosis  and  cases  of  recent  infection  that  have 
subsided  are  not  suitable  cases  for  arthroplasty.  In  operation,  in  addi- 
tion to  the  usual  protection  of  the  field  of  operation,  after  the  skin  and 

264 


OPERATIVE  TREATMENT  IN  JOINT  ANKYLOSIS  265 

fat  have  been  incised,  towels  should  be  clamped  to  the  edges  of  the  skin 
as  an  extra  protection. 

307.  Arthroplasty  in  Ankylosis  of  the  Wrist. — In  ankylosis  of  the 
wrist  very  good  motion  and  function  are  possible  by  a  complete  incision 
of  all  the  carpal  bones  as  described  (see  Excision  of  the  Wrist). 

The  function  is  usually  so  good  that  an  arthroplasty  is  uncalled  for 
at  this  joint. 

A  stiff  wrist  should  not  be  interfered  with  in  cases  of  chronic  rheu- 
matism where  the  fingers  and  other  joints  in  the  arm  are  affected  by 
rheumatism  unless  it  is  badly  deformed  or  unless  the  patient  is  very 
healthy  and  the  rheumatism  has  entirely  subsided.  Where  the  disease 
is  of  an  infectious  or  tubercular  nature  and  in  the  wrist  only  and  where 
the  patient  is  in  good  health,  an  excision  at  the  wrist  may  be  done  to 
relieve  the  ankylosis. 

308.  Arthroplasty  for  Ankylosis  of  the  Finger. — A  dorsal  incision 
is  made  just  to  the  side  of  the  tendon  between  it  and  the  artery;  usually 
two  dorsal  incisions  are  necessary:  They  are  carried  carefully  down 
through  the  periosteum,  a  long  handled  small  osteotome  is  used  to  raise 
the  periosteum  completely  from  the  two  bones  without  disturbing  the 
tissues  between  the  periosteum  and  the  skin.  The  lateral  ligaments  of 
the  joint  are  removed  in  a  similar  way.  The  necessary  bone  is  removed 
to  allow  easy  motion  of  the  joint.  The  bones  are  shaped  as  nearly  as 
possible  to  conform  to  the  natural  shape  of  the  joint.  A  flap  of  fascia 
is  cut  from  the  thigh  and  placed  over  the  end  of  the  bones  and  sutured 
to  one  bone  overlapping  its  end.  The  finger  fibrous  tissue  may  be  used 
for  the  same  purpose.  There  is  less  disturbance  of  the  mechanism  of 
the  fingers  by  diminishing  the  dissection  and  using  fascia  lata. 

The  incisions  are  closed  with  chromic  catgut  number  00.  Enough 
bone  should  be  removed  to  allow  easy  motion.  There  should  be  very 
little  disturbance  of  the  other  tissues. 

The  finger,  hand  and  wrist  are  immobilized  on  a  palmar  splint  ex- 
tending to  the  elbow.  Gentle  passive  motion  is  allowed  after  seven  to 
ten  days,  depending  on  the  amount  of  pain  and  swelling. 


CHAPTER  V 

.  OPERATION   IN   SUPPURATIVE    CONDITIONS 

309.  Suppurative  Condition  at  the  Wrist. — When  the  condition  at 
the  wrist  is  one  of  severe  acute  suppuration,  the  anterior  and  posterior 
with  the  radial  incision  should  be  used,  the  disease  well  drained,  the 
abscess  cavity  washed  with  salt  solution  and  wiped  out  with  gauze 
strips.  When  necessary  the  bone  is  incised  and  cleaned  out  with  a  chisel 
or  osteotome.  After  operation  the  incisions  are  kept  wide  at  the  corners 
with  gauze  and  tubes  placed  between  them. 

A  stiff  wrist  often  results  from  suppurative  conditions.  Motion  is 
always  obtainable  by  operative  measures  unless  the  tendons  are  exten- 
sively involved  in  the  adhesions.  A  constantly  painful  and  weak  wrist 
is  disabling  when  due  to  chronic  suppuration.  Drainage  followed  by 
an  excision  or  an  excision  from  the  first  is  justifiable  and  gives  a  very 
excellent  result  when  carefully  done.  Any  very  acute  suppurative  con- 
dition should  be  allowed  to  subside  after  drainage  and  an  excision  then 
done  will  give  promise  of  excellent  wrist  motion.  If  the  condition  is 
sub-acute  the  disease  may  be  removed  and  an  excision  done  at  the  same 
time.  The  joint  should  be  immobilized  and  the  fingers  allowed  to  have 
free  motion.    See  Carrell-Dakin  Technique,  section  323. 

310.  Osteomyelitis  at  the  Wrist. — In  osteomyelitis  an  operation 
should  be  done  as  early  as  possible  after  making  the  diagnosis.  In  sub- 
acute cases,  incision  and  drainage  are  all  that  is  necessary.  Whenever 
incising  for  abscess  all  the  pockets  should  be  opened  and  if  the  abscess 
is  large,  counter  incisions  are  made  at  dependent  portions.  The  pus 
pocket  should  be  opened  freely,  wiped  out  with  gauze,  irrigated  and 
wiped  out  again  with  gauze.  Curetting  should  be  avoided  excepting  for 
the  removal  of  sinuses  in  the  skin,  and  in  cases  of  sinuses  it  is  often  better 
to  excise  them.  Perforated  rubber  tubing  should  be  placed  to  drain 
the  deepest  portion  of  each  pocket.  The  skin,  fat  and  superficial  muscle 
layers  should  be  made  to  gap  by  means  of  gauze  drains.  At  the  end 
of  ten  days  the  gauze  is  removed  and  the  tubes  shortened.  The  tubes 
are  gradually  drawn  out  a  little  each  day  or  two  until  not  used. 
This  method  makes  the  repeated  reapplication  of  drains  and  wicks 
unnecessary  as  the  wound  will  gap  of  itself  and  close  from  the  bottom 
if  the  surgeon  has  been  careful  to  make  large  incisions. 

Where  this  is  necessary,  the  incisions  should  be  large  and  a  counter 
incision  should  be  made  on  the  other  side  of  the  bone  with  a  hole  made 
in  the  bone.  Splints  should  always  be  applied  to  immobilize  the  limb. 
They  should  be  placed  so  that  they  will  not  interfere  with  the 
dressing.      In  some  instances  it  is  better  to   apply  a   plaster  with 

266 


OPERATION  IN  SUPPURATIVE  CONDITIONS  267 

large  windows  and  ropes  to  give  stability.  The  dressings  should  be 
done  every  day  or  twice  a  day,  depending  on  the  foul  condition 
of  the  discharge.  If  the  odor  is  excessive  chlorinated  soda  dress- 
ing should  be  used  diluted,  using  it  x\i,  '/s,  lfi  the  U.  S.  P.  strength. 
The  gauze  drains  should  remain  for  at  least  ten  days  without  being  dis- 
turbed. When  removed  granulations  will  be  formed  under  them  in  such 
a  way  as  to  keep  the  wound  open  without  applying  drains.  Irrigation 
may  be  used  at  the  time  of  the  operation  and  the  wound  thoroughly 
wiped  out  with  gauze  afterwards.  No  irrigation  or  probing  or  applica- 
tion of  wicks  will  be  necessary  if  the  first  drains  are  left  in  long  enough. 
After  the  first  ten  days  the  tubes  are  shortened  gradually  until  they  are 
not  needed.     See  section  323. 

In  severe  cases  where  the  patient  is  unconscious  or  delirious  the  bone 
should  always  be  opened.  No  tight  packing  should  be  used,  as  this 
interferes  with  good  drainage.  Where  sequestra  have  formed  they  should 
be  removed.  An  x-ray  should  be  taken  whenever  possible  to  determine 
the  position  of  the  disease  (unless  the  case  is  urgent  and  an  immediate 
x-ray  is  not  obtainable). 

In  cases  of  long  standing  that  are  sub-acute  at  the  time  of  first  exami- 
nation, where  the  bone  is  riddled  with  holes  over  an  extremely  long  area, 
it  is  impossible  often  to  remove  the  dead  bone  satisfactorily  without 
removing  all  the  bone.  In  these  cases  free  incision  down  to  the  bone 
with  frequent  openings  into  the  bone  as  described  above,  will  allow  the 
septic  process  to  run  its  course  and  the  sequestra  to  gradually  separate. 

Where  sequestra  are  present  it  is  always  desirable  to  remove  them  as 
soon  as  they  have  separated,  provided  the  involucrum  is  strong  enough 
to  act  as  a  support.  Sequestra  may  be  superficial  or  in  the  medullary 
cavity  or  both.  Where  there  is  a  persistent  sinus  and  a  sequestrum  is 
present,  pus  will  continue  to  form  until  the  sequestrum  is  removed. 
Cases  discharging  several  years  where  a  sequestrum  is  present  may  close 
in  a  few  weeks  after  removal  of  the  sequestrum.  See  Carrell-Dakin 
Technique,  section  323. 

311.  Excision  of  the  Wrist.— When  removal  of  one  or  more  bones' 
is  necessary  as  in  tuberculosis,  a  better  result  as  to  function  is  obtained 
when  all  the  bones  are  removed  with  perhaps  the  exception  of  the 
pisiform  and  perhaps  the  trapezius;  the  unciform  process  of  the  unciform 
may  be  left.  Even  when  only  one  bone  is  diseased  there  is  less  danger 
of  stiffness  by  a  complete  excision.  There  is  never  abnormal  mobility 
if  the  operation  is  done  subperiosteally  even  though  all  the  carpal  bones 
are  removed.  An  excision  of  the  wrist  will  give  a  useful  wrist  with  one 
or  two-thirds  or  more  of  the  normal  flexion  and  extension.  When  the  op- 
eration is  done  for  a  stiff  wrist  due  to  deformity,  old  fracture  or  inflamma- 
tion that  has  subsided,  very  excellent  results  as  to  function  are  possible 
if  the  operator  is  careful  to  minimize  the  trauma  in  gentle  handling  of 
tissues,  to  use  long  incisions  so  that  retraction  is  possible  without  separa- 
tion of  the  delicate  structures.    Any  adhesions  that  limit  motion  of  the 


26S  TECHNIQUE  OF  OPERATIONS 

tendons  should  be  noted  before  operation  and  the  fingers  manipulated 
but  not  roughly  to  relieve  this.  If  excision  is  decided  upon  no  rough 
handling  or  breaking  up  of  adhesions  should  be  done  at  the  time  of 
operation.  The  removal  of  the  carpus  will  relieve  many  of  the  adhesions 
and  make  extensive  manipulation  unnecessary.  After  the  operation  the 
action  of  all  the  joints  of  the  fingers  must  be  noted  and  the  fingers 
manipulated  so  that  their  action  will  be  unrestricted. 

When  the  operation  is  done  for  suppurative  conditions,  conservative 
treatment  should  be  tried  first  unless  the  disease  is  acute  or  of  long 
standing,  or  extremely  painful  and  conservative  treatment  has  proved 
ineffective. 

OPERATION 

(Excision  of  the  wrist)  Ollier's  incision 

Oilier  advises  three  incisions  for  suppurative  conditions,  an  anterior 
lateral,  a  posterior  and  a  small  external  for  drainage  when  necessary. 

The  arm  is  evasculated  by  an  esmark  and  tourniquet  (the  tourniquet 
is  applied  over  a  towel  for  a  short  time  only).  The  skin  having  been 
carefully  prepared  and  the  field  of  operation  protected,  the  arm  rests 
on  a  small  table  to  one  side  of  the  operating  table.  The  operator  sits 
facing  the  side  of  the  table,  his  assistant  faces  him.  The  arm  is  pronated 
and  rests  on  a  sand  bag. 

Posterior  incision 

An  incision  is  made  midway  between  the  styloids  starting  one  inch 
above  them  and  extending  vertically  downward  through  the  posterior 
annular  ligament  to  the  middle  of  the  second  metatarsal  along  the  outer 
side  of  the  extensor  indicis.  The  dissection  is  carried  down  to  the  peri- 
osteum, the  extensor  indicis  is  to  be  retracted  inward  and  the  extensor 
secondi  internodii  outward.  The  extensor  carpi  raclialis  longus  and 
brevis  should  be  spared  and  detached  subperiosteal^  (see  figure  410). 

Anterior  incision 

A  palmar  incision  is  made  over  the  radial  border  of  the  ulna  starting 
one  inch  above  the  styloid  process  and  extending  to  the  base  of  the  fifth 
metatarsal,  leaving  the  flexor  carpi  ulnaris  to  the  inner  side.  This  inci- 
sion is  carried  down  to  the  periosteum  (figure  411). 

(Excision  of  the  wrist)  radial  incision 

A  third  incision  is  now  made  when  necessary  (see  figure  411),  one 
inch  long  over  the  styloid  process  of  the  radius;  it  is  carried  down  to  the 
bone  and  made  before  removing  the  carpus.  For  complete  drainage 
for  tuberculous  or  purulent  disease,  three  incisions  are  made.  The 
operation  is  continued  as  the  case  requires. 

For  adjustment  of  fractures,  correction  of  deformity  or  excision,  where 


OPERATION  IN  SUPPURATIVE  CONDITIONS  269 

there  is  no  active  disease  the  posterior  and  anterior  are  all  that  are 
necessary. 

The  operator  carries  each  incision  described  above  in  turn  through  the 
periosteum  to  the  bone.  Lifting  the  periosteum  with  a  small  long 
handled  osteotome.  It  is  to  be  retracted,  leaving  the  surface  of  the 
bones  uncovered  of  periosteum  and  the  tendons  and  their  sheath  un- 
touched. Wide  separation  of  the  overlying  tissues  en  masse  with  the 
periosteum  is  necessary.  The  surgeon  is  now  ready  for  the  third  step, 
the  removal  of  one  bone  after  another. 

After  removal  or  adjustment  of  the  bones,  the  surgeon  has  the  tourni- 
quet removed.  The  deep  tissues  and  periosteum  are  brought  together 
with  interrupted  chromic  catgut  sutures  number  00,  the  subcutaneous 
fat  with  interrupted  chromic  catgut  sutures  number  00,  the  skin  with 
continuous  chromic  catgut  sutures  or  horsehair.  When  suppurative 
disease  is  present  the  bones  are  removed,  preferably  with  a  small  long 
handled  osteotome.  This  instrument  is  used  to  separate  the  bones  from 
the  periosteum.  The  interosseous  periosteum  is  removed  with  the  bones 
leaving  one  large  cleaned  out  cavity.  This  is  wiped  out  with  sponges 
and  washed  with  salt  solution  when  there  is  much  suppuration.  The 
ends  of  the  metacarpal,  the  ulna  and  radius  are  inspected  and  any  dis- 
ease here  removed.  The  styloids  should  be  left  in  all  cases  even  when 
other  bone  must  be  removed. 

Excision  of  the  wrist 

In  case  of  children  where  there  is  good  bone  and  then  suppuration 
beyond  it  in  the  epiphysis,  the  diseased  bone  is  wiped  with  a  sponge  and 
an  extra  incision  made  directly  over  it  to  give  immediate  drainage,  but 
the  epiphysis  should  be  left  unharmed,  the  surgeon  depending  on  good 
drainage  to  the  epiphysis.  The  diseased  bone  is  not  removed  at  this 
point.  The  tendons,  sheaths  and  ligaments  should  be  untouched  with 
their  contiguous  periosteum.  If,  however,  the  disease  has  penetrated  to 
these  tissues,  it  should  be  dissected  away  carefully.  After  completely 
clearing  out  the  whole  cavity  it  is  washed  out  with  salt  solution  and 
sponged  out  with  gauze  strips.  After  inspection,  if  the  whole  cavity  is 
satisfactorily  cleaned  out,  the  tourniquet  is  removed.  Large  wads  of 
gauze  are  made  to  gap  the  wounds  at  their  corners  and  drainage  tubes 
placed  between.  The  third  incision  is  used  for  drainage  in  suppura- 
tive cases  only  as  described  above. 

After  treatment 

The  tubes  and  gauze  remain  for  eight  to  ten  days  and  can  then  be 
safely  removed  and  no  other  drains  inserted.  After  operation  a  wire 
splint  or  plaster  is  applied  holding  the  hand,  forearm  and  upper  arm 
firmly;  the  elbow  at  right  angles.  It  should  be  applied  so  that  inspec- 
tion and  all  soiled  dressing  can  be  changed  without  disturbing  the  splint. 


270  TECHNIQUE  OF  OPERATIONS 

The  windows  in  the  plaster  or  open  places  in  the  splint  should  leave  a 
margin  of  healthy  skin  beyond  the  incision  at  either  end  so  that  the 
splint  can  be  kept  clean.  The  splint  should  allow  free  motion  of  the 
fingers  at  the  metatarsal  phalangeal  joints  and  beyond.  Active  motion 
of  the  fingers  is  encouraged  on  the  fourth  day  and  gentle  passive  motion 
if  the  active  motion  is  not  satisfactory.  The  splint  is  removed  a  little 
each  day  after  the  eighth  week  unless  the  suppuration  is  severe.  In 
non-suppurative  cases  the  splint  is  removed  about  the  fifth  week  a  little 
at  a  time  until  the  muscles  are  strong  enough  to  support  the  wrist. 

312.  Operation  for  Bone  Disease  in  the  Metacarpal  or  Phalangeal 
Bones  or  their  Joints. — An  incision  is  made  on  the  dorsum  of  the 
finger  between  the  tendon  line  and  the  artery  (figures  423  and  424). 
The  incision  is  made  with  the  scalpel  carefully  down  through  the  perios- 
teum. A  small  long  handled  osteotome  is  used  to  raise  the  periosteum 
from  the  bone.  This  is  retracted  without  disturbing  the  structures 
between  the  periosteum  and  the  skin.  In  children  the  epiphysis  should 
be  interfered  with  as  little  as  possible,  a  quadrilateral  door  is  taken  out 
of  the  shaft  of  the  bone  not  extending  to  the  epiphysis  in  children  even 
when  it  is  diseased.  The  cavity  is  wiped  out,  a  tube  or  rubber  drain  in- 
serted, and  gauze  is  used  to  gap  the  soft  tissues.  These  drains  are  left 
ten  days,  the  dressing  done  after  the  operation  or  the  third  or  fourth  day 
and  as  often  as  necessary  without  disturbing  the  drains.  These  are 
shortened  after  the  tenth  day  and  later  omitted.  By  this  method  the 
sinus  will  remain  open  without  reapplying  drains. 

The  forearm,  wrist  and  fingers  are  held  on  a  splint  for  a  week  or  ten 
days;  after  that  the  unaffected  fingers  should  be  allowed  freedom  and  the 
patient  encouraged  to  use  them.  In  some  cases  there  is  a  swelling  at 
the  base  of  the  wrist  on  the  palmar  side;  in  these  cases  and  when  the 
dorsum  of  the  hand  is  swollen,  there  is  a  palmar  abscess  which  will 
have  to  be  drained  especially  if  the  patient  is  acutely  ill.  If  there  is  no 
great  virulence,  but  the  hand  is  swollen,  the  wrist  and  forearm  may  be 
opened  as  well  as  the  finger.  The  operator  must  be  guided  by  the 
presence  of  pus,  the  general  and  local  reaction.  In  any  acute  process 
daily  soaks  in  antiseptic  solution  will  be  indicated  for  the  whole  arm 
and  hand,  with  or  without  poultices,  the  old  flaxseed  poultices  are 
usually  the  best  unless  they  irritate  the  skin. 

The  treatment  of  the  metacarpal  bone  is  the  same  as  that  laid  out  for 
the  phalangeal  bones.    The  axillary  glands  should  be  examined. 

313.  Methods  and  Principles  of  Drainage  in  Acute  Non-tubercular 
Suppurative  Joint  Disease.  Wrist  and  Hand — A  small  suppurative 
focus  without  virulence  or  active  constitutional  disturbance  should  be 
drained  by  a  suitable  incision  wiped  out  with  gauze,  a  tube  placed  to  its 
deepest  part  and  the  soft  tissues  gaped  with  gauze. 

When  there  is  a  great  deal  of  constitutional  disturbance  drainage  and 
counter  drainage  should  always  be  the  rule.  If  the  bone  is  involved 
this  should  be  opened.      The  pus  cavities  in  the  soft  tissues  should  be 


OPERATION  IN  SUPPURATIVE  CONDITIONS  271 

wiped  out.  No  extensive  bone  operation  should  be  done  otherwise. 
The  bone  should  be  drained  with  tubes  to  the  remote  portions  and  the 
muscle,  fat  and  skin  gaped  by  gauze.  These  operations  are  done  quickly 
and  should  not  be  prolonged,  but  efficient  drainage  and  counter  drainage 
should  be  established  unhesitatingly.  The  joint  is  immobilized  and 
the  fingers  left  free  after  all  operations  for  suppurative  conditions  of  the 
bone  or  joint  near  the  wrist  when  possible. 

In  any  extensive  non-tubercular  suppurating  bone  disease  about  the 
wrist  or  hand  anterior  and  posterior  incisions  should  be  made  at  the 
wrist  and  on  the  back  of  the  hand  and  back  of  the  fingers  when  neces- 
sary. If  the  patient  is  very  ill  the  operation  should  be  done  very  rap- 
idly and  good  drainage  established.  See  Carrell-Dakin  Technique, 
section  323. 


PART  VII— MISCELLANEOUS  OPERATIONS 
CHAPTER  I 

MISCELLANEOUS    OPERATIONS 

314.  Torticollis  Operation.  (Figures  414  to  418.) — The  patient  lies  on 
his  back  with  a  sand  bag  or  hard  pillow  under  his  shoulders  so  there  is 
slight  tension  on  the  sternocleidomastoid  muscles.  The  tense  muscle 
should  be  carefully  noted  before  the  patient  is  anaesthetized  so  that  there 
will  be  no  doubt  as  to  which  side  is  to  be  operated  on.  Under  anaesthesia 
it  is  often  impossible  to  tell  which  muscles  are  contracted.     The  head 


Fig.  414. — The  two  portions  of 
the  sternocleidomastoid  are  ex- 
posed. The  skin  incision  should  be 
very   small    and    stretched   inward  Fig.  415.— A  few  muscle  fibers  at  a 

and  outward  to  reach  both  portions  time  are  divided  on  a  director, 

of  the  muscles.     (See  figures  218, 
219.) 

and  thorax  and  shoulder  are  properly  covered  to  protect  the  field  of 
operation.  An  incision  may  be  made  one  and  one-half  inches  above 
the  clavicle  and  parallel  to  it  just  above  the  clavicle  or  just  below  the 
clavicle. 

When  operating  on  a  boy  the  incision  over  the  clavicle  is  very  service- 
able. In  operating  on  a  girl  an  incision  that  will  be  covered  by  a  neck- 
lace or  a  neck  band  is  often  preferred.  For  this  reason  an  incision 
higher  up  is  sometimes  chosen.  The  skin  in  this  region  is  very  elastic 
and  can  be  drawn  up  and  down  laterally  without  difficulty.  For  this 
reason  the  incision  need  not  be  more  than  three-fourths  of  an  inch  long. 
If  the  incision  is  made  over  the  clavicle  it  is  started  an  inch  from  the 

273 


274 


TECHNIQUE  OF  OPERATIONS 


sternal  end  of  the  clavicle  and  extends  three-fourths  of  an  inch  outward. 
The  incision  is  retracted  inward  while  the  operator  separates  the  fibers 
of  the  inner  end  of  the  sternocleidomastoid  and  its  sheath.  The  incision 
is  gradually  drawn  outward  as  the  outer  fibers  of  the  sheath  and  muscle 
are  cut.  A  director  is  used  to  lift  a  few  fibers  of  the  muscle  at  a  time  in 
order  to  avoid  unnecessary  bleeding.  Very  rarely  there  is  a  moderately 
large  vessel  in  the  sternomastoid  which  bleeds  after  the  muscle  drops 
back  in  the  wound.  The  operator  should  be  careful  not  to  miss  these 
vessels,  remembering  that  when  the  muscle  fibers  are  lifted  on  a  director 
they  are  tense  and  bleeding  will  not  occur  until  after  the  fibers  are  re- 
laxed.    As  the  posterior  sheath  of  the  muscle  is  reached,  the  operator 


Fig.  416. — Both  portions  of  the 
muscle  and  its  sheath  must  be  com- 
pletely divided. 


Fig.  417. — On  the  neck  a  small 
incision  can  be  pulled  to  one  side 
and  then  moved  to  the  other,  ex- 
posing small  portions  of  the  muscle 
at  a  time.  In  this  figure  the  incision 
is  moved  outward,  in  the  next  figure 
inward. 


should  take  care  not  to  injure  the  carotid  sheath.  The  jugular  sheath 
is  not  readily  distinguished  from  the  layers  of  fascia.  If  the  muscle  is 
very  vascular  it  may  be  tied  off  and  the  fibers  cut  afterwards.  Should 
any  extensive  oozing  occur,  packing  with  gauze  strips  for  five  or  ten 
minutes  is  usually  all  that  is  necessary.  When  the  operation  is  complete 
the  operator  should  see  that  no  fibers  of  the  sheath  and  the  muscle  are 
left.  He  should  put  his  finger  in  the  wound  and  trace  the  anterior  edge 
of  the  clavicle,  the  upper  edge,  and  the  posterior  edge,  looking  for  uncut 
fibers  from  the  interclavicular  notch  outward.  The  fibers  most  com- 
monly overlooked  are  superficial  ones  immediately  under  the  skin  and 
fat.  These  are  more  often  neglected  while  the  attention  is  concentrated 
on  the  deeper  portions  of  the  muscle.  The  string-like  fibers  that  are 
sometimes  overlooked  do  not  materially  interfere  with  the  correction 
of  the  deformity  when  the  operation  is  otherwise  well  done;  they  do 
interfere  more  or  less  with  the  cosmetic  effect  afterward.  Suture. — The 
subcutaneous  fat  is  brought  together  with  interrupted  chromic  catgut 


MISCELLANEOUS  OPERATIONS 


275 


sutures  firmly  enough  so  that  there  will  be  no  tension  on  the  over- 
lying skin.  The  skin  is  brought  together  with  a  subcutaneous  suture 
and  painted  with  compound  tincture  of  benzoin,  not,  however,  if 
iodine  was  used.  Four  layers  of  gauze  a  little  longer  than  the  incision 
and  an  inch  wide  are  placed  over  the  incision  and  painted  with  com- 
pound tincture  of  benzoin.  This  practically  seals  the  wound  before 
it  is  healed.     The  dressing  may  be  inspected  at  the  end  of  the  fifth  day. 

In  cases  of  spasmodic  torticollis,  a  portion  of  the  sternocleidomastoid 
is  often  removed  instead  of  cutting  it  across. 

Tillaux  and  Lange  prefer  cutting  the  sternocleidomastoid  close  to  the 
mastoid  process.  When  an  operation  is  done  here  the  incision  is  made 
over  the  mastoid  process,  the  muscle  should  be  cut  close  to  the  bone. 
The  after  treatment  is  the  same  with  this  exception,  that  the  correction 


Fig.  418.  —  The  incision  is 
moved  inward;  in  the  figure  pre- 
ceding it  is  moved  outward,  ex- 
posing each  part  of  the  muscle. 


Fig.  419. — Showing  a  method  of 
overlapping  a  stretched  out  mus- 
cle. 


of  the  head  should  not  be  undertaken  until  the  fourth  or  fifth  day  of 
convalescence;  moreover,  the  correction  should  be  gradually  increased 
every  second  day  as  there  is  often  too  much  strain  on  the  pneumogastric 
nerve  if  overcorrection  is  instituted  at  once. 

The  success  of  the  operation  in  congenital  torticollis  depends  first  on 
thoroughness,  making  sure  that  no  fibers  of  the  muscle  of  the  sheath  are 
left  uncut;  second,  maintaining  an  overcorrected  position  of  the  head 
after  operation  for  nine  or  ten  months.  The  first  four  to  six  weeks  a 
plaster  of  Paris  is  used,  later  a  well  fitting  brace  maintaining  overcorrec- 
tion. This  apparatus  is  not  uncomfortable  as  soon  as  the  patient  gets 
used  to  wearing  it.  The  plaster  (figures  420,  422),  should  include  the 
head  and  thorax;  the  ears  and  top  of  the  head  should  always  be  left  out. 
In  order  to  maintain  the  position  of  the  head,  the  chin,  the  occiput  and 
forehead  must  be  held.  After  operations  on  the  right  sternocleido- 
mastoid, the  chin  should  be  turned  to  the  right.  The  left  ear  should  be 
depressed  toward  the  left  shoulder  and  the  cervical  spine  should  be  left 


276 


TECHNIQUE  OF  OPERATIONS 


in  a  straight  position  otherwise.     After  operations  on  the  left  muscle 
the  position  is  reversed. 

315.  Operation  for  Tenosynovitis. — When  a  tenosynovitis  has  not 
responded  to  conservative  treatment  it  is  sometimes  necessary  to  oper- 
ate, especially  when  it  is  tubercular.  Incision  and  drainage  are  not 
sufficient.  The  tendon  sheath  must  be  completely  exposed  by  a  gener- 
ous incision,  and  carefully  dissected  away  from  the  tendon  throughout 
its  entire  length.  The  tendon  may  be  covered  with  sterile  vaseline  and 
replaced  and  the  skin  closed  so  that  the  tendon  will 
not  adhere  to  it.  Fat  or  fascia  may  be  used  to  pre- 
vent adhesions.  This  is  the  only  operative  measure 
that  gives  complete  satisfaction  in  extensive  cases. 


Fig.  420.— Torticollis 
plaster.  The  chest  por- 
tion is  applied  over  sheet 
wadding.  The  shoulder 
"plaster  ropes"  are  ap- 
plied over  felt.  The 
chin,  head,  occiput  and 
forehead  portions  are 
applied  over  felt.  The 
shoulder  rope  is  turned 
back  while  it  is  soft. 
(See  figures  421  and 
422.) 


Fig.  421.— The  body 
and  head  portions  are 
connected  by  plaster 
ropes  while  they  are 
wet.  Plaster  bandages 
are  folded  over  them 
and  incorporated  into 
the  plaster.  (See  fig- 
ure 422.) 


Fig.  422.— When  the 
plaster  is  finished,  the 
portion  over  the  top  of 
the  head  is  cut  away, 
allowing  the  head  to  be 
taken  care  of,  the  ears 
should  be  free,  the  plas- 
ter should  be  light. 


Small  local  conditions  may  be  excised,  removing  a  small  portion  of  the 
sheath  above  and  below.  The  part  should  be  immobilized  for  about 
a  week  and  then  motion  of  the  tendon  encouraged  six  or  eight  times  a 
day,  and  the  immobilization  reapplied. 

316.  Bone  Grafting. — In  considering  bone  grafting,  the  operator 
should  remember  certain  things  which  underlie  the  success  of  this  opera- 
tion. Absolute  asepis  to  the  smallest  detail  is  essential.  The  bone  to 
be  grafted  should  be  completely  prepared  before  cutting  the  graft. 
The  graft  should  fit  snugly  and  be  held  in  place  by  sutures  or  pegs. 
Whatever  shape  and  type  of  graft  and  for  whatever  purposes  used,  the 
human  graft  either  from  the  patient  or  another  patient  is  better  than  a 
graft  taken  from  an  animal.  The  graft  should  have  a  good  bony  con- 
tact at  each  end  with  the  medulla  of  the  bone  to  which  it  is  attached. 


MISCELLANEOUS  OPERATIONS 


277 


Both  ends  of  the  graft  beyond  the  bridge  should  have  as  long  a  surface 
of  contact  as  possible.  Whenever  possible  this  surface  of  contact 
should  be  at  least  two  inches.  When  the  tissues  about  the  bone  to 
be  grafted  are  very  debilitated  or  the  soft  parts  very  sclerosed  from 
extensive  scar  formation  or  injury  as  in  certain  old  ununited  fractures, 
the  fibrinous  union  between  the  ends  is  not  removed  except  where  the 
trough  is  made  for  the  graft  inlay.  There  will  be  much  less  disturb- 
ance of  the  tissue  by  this  method  and  the  repair  in  the  extremely  de- 
bilitated will  be  better  than  if  the  bones  had  been  completely  cleared  on 
all  sides. 

When  operating  on  healthy  ununited  fractures,  large  dissections 
may  be  done  if  necessary  with  impunity.  With  the  debilitated  and  in 
the  presence  of  extensive  sclerosed 
tissues  a  minimum  amount  of 
trauma  should  be  caused.  (See 
Hibbs  operation  and  Albee  opera- 
tion.) 

In  these  cases  the  bone  to  be 
operated  on  is  uncovered  by  a 
flap  of  fat  and  skin,  the  incision 
of  which  is  some  distance  from 
the  bone.  When  the  flap  is  turned 
back  the  deeper  tissues  are  incised 
directly  over  the  bone  in  another 
line  under  the  flap.  Too  much 
cannot  be  urged  in  favor  of  the 
large  and  long  graft.  Small,  short 
grafts  should  be  used  as  infre- 
quently as  possible.  If  there  has 
been  any  inflammatory  process 
with  infection,  no  operation  for 
bone  grafting  should  be  done  until 
nine  months  or  a  year  after  the 
disappearance  of  all  symptoms  of  inflammation.  Method  of  suturing 
the  graft  in  place  is  illustrated  (see  figure  423).  The  graft  may  be 
pegged  with  small  bone  pegs  or  by  means  of  bone  screws  filling  a  tap 
drilled  in  the  bone  cortex. 

317.  Operation  for  Rachitic  Deformities. — In  operating  for  bone 
deformities  in  rickets,  an  x-ray  should  be  used  to  determine  the  advis- 
ability of  operating;  where  the  epiphysis  show  a  fringy  indefinite  outline 
it  is  better  to  defer  the  operation.  When  the  epiphyseal  line  is  clear  in 
the  x-ray,  the  deformities  may  be  corrected  by  osteotomy  as  described 
in  these  pages.  Immobilization  of  the  cut  bone  should  be  very  perfect, 
the  deformity  over  corrected.  After  six  weeks  of  bed  and  plaster  of 
Paris  bandages  the  patient  is  allowed  to  walk  with  the  plaster  on.  When 
the  rickets  is  still  active,  general  hygiene,  orange  juice  and  anti-rachitic 


Fig.  423. — Diagram  showing  inlay  bone 
graft.  A,  The  graft  in  place  held  by  catgut 
or  kangaroo  sutures.  B,  Bone  graft  showing 
grooves  for  the  suture.  C,  A  cross  section  of 
bone  showing  drill  holes  for  suture  and 
method  of  applying  the  sutures.  D,  Cross 
section  of  bone  showing  graft  in  shaded  lines 
and  the  sutures  holding  it. 


278  TECHNIQUE  OF  OPERATIONS 

diet  should  be  prescribed.  The  apparatus  to  maintain  correction  of  the 
deformity  should  be  worn  for  about  a  year.  Activity  should  be  en- 
couraged but  with  two  to  four  hours  of  rest,  daily,  depending  on  the 
active  condition  of  the  rickets  and  depending  on  the  strength  of  the  child. 

318.  Arthroplasty  of  the  Tempomaxillary  Joint. — Ankylosis  at  the 
tempomaxillary  joint  as  pointed  out  by  Dr.  Murphy  may  be  articular 
or  extra  articular.  An  incision  is  made  above  the  zygoma  and  parallel 
to  it  down  to  the  fascia  and  not  through  it. 

An  incision  is  made  from  the  posterior  region  of  the  ascending  ramus 
displacing  the  parotid  and  facial  nerves  without  injuring  them.  The 
vertical  portion  of  the  incision  is  one  or  two  inches  long  from  the  lower 
margin  of  the  zygoma  straight  up  into  the  hair,  passing  in  front  of  the 
ear.  When  the  bone  has  been  freed  and  a  small  portion  removed  a  flap 
is  taken  from  the  temporal  fascia  and  interposed  between  the  divided 
surfaces.  The  coronoid  may  be  found  ankylosed  to  the  skull  in  addition 
to  ankylosis  of  the  temporo-mandibular  joint.  This  must  be  relieved 
by  osteotomy  and  interposition  of  fascia  to  prevent  bony  union. 

319.  Infantile  Paralysis. — Operations  in  infantile  paralysis  are  for- 
tunately not  necessary  in  the  majority  of  cases;  very  slight  cases  may 
be  improved  by  muscle  training  and  development  exercises.  The  object 
of  all  treatment  is  to  secure  strength  and  stability  at  each  joint  about 
which  paralyzed  or  partially  paralyzed  muscles  play.  To  secure  this, 
the  joint  must  be  made  stable  and  firm  and  the  muscles  equalized  or 
balanced.  While  it  is  true  that  the  majority  of  poliomyelitis  cases  do  not 
require  operation,  there  are  a  selected  few  of  the  mild  cases  that  are 
greatly  benefited  by  it. 

As  there  may  be  a  partial  paralysis  in  the  individual  muscle,  or  there 
may  be  a  total  paralysis  of  one  or  all  of  the  muscles,  the  deformities  and 
disabilities  are  correspondingly  numerous  giving  an  infinite  variety  of 
possibilities  in  the  operative  treatment.  A  selection  of  the  operation 
must  be  based  on  a  careful  observation  of  the  individual  case. 

Care  should  be  taken  early  in  the  disease  to  develop  the  muscle  and 
prevent  deformity.  In  neglected  cases  or  cases  where  the  muscles  have 
developed  unevenly,  deformity  and  contractures  are  often  present; 
these  must  be  corrected  and  the  muscles  brought  to  as  high  a  state  of 
efficiency  as  possible,  then  operations  to  improve  stability  of  the  joint, 
to  improve  motion  of  the  joint,  and  to  improve  locomotion  as  a  whole, 
are  advisable. 

In  infantile  paralysis,  no  operation  should  be  considered  early  in  the 
disease  and  no  operation  (excepting  those  to  relieve  deformities  and 
contractures)  should  be  done  until  the  second  or  third  year  after  the 
onset  of  the  disease.  Deformities  should  be  corrected  by  operation  or 
otherwise  as  early  as  possible  in  order  to  allow  the  tissues  to  re- 
cover, then  the  muscles  and  tissues  should  be  brought  to  as  high  a  state 
of  function  as  possible. 

When  deformities  and  contractures  have  existed  and  are  relieved  by 


MISCELLANEOUS  OPERATIONS 


279 


operation  there  will  be  much  gain  in  the  strength  and  the  development 
of  the  limb.  Deformities  and  contractures  that  are  extreme  when  re- 
lieved will  often  allow  the  muscles  to  gain  a  great  deal,  especially  if  the 
surgeon  understands  the  training  of  muscles  in  paralytic  conditions. 
Slight  deformities  left  uncorrected  often  impede  the  recovery  of  partly 
paralyzed  muscles. 

The  operations  which  are  undertaken  to  increase  the  usefulness  of  the 
leg  should  never  be  done  until  deformities  have  been  relieved  and  the 

muscles  trained.  The  question 
as  to  which  operation  is  most 
appropriate  for  the  individual 
case  is  a  matter  largely  of  judg- 
ment. Operations  will  relieve 
disability,  aid  in  locomotion 
and  give  better  function  and 
often  make  braces  unnecessary. 
The  operations  are  considered 
in  the  different  chapters  ac- 
cording to  the  joint  affected  by 
the  paralysis. 


Fig.  424. — Skin  and  fat  incision  for  plastic 
operation  on  the  spine  or  for  lamenectomy.  The 
ends  of  the  incision  do  not  cross  the  median  line. 


320.  Plastic    Operation    on 
the  Spine  for  Potts  Disease. — 

A  plastic  operation  on  the  spine 
to  fix  the  spine  in  Potts  disease 
has  been  a  valuable  contribu- 
tion to  the  treatment  in  many 
cases.  There  is  very  little 
choice  between  Dr.  Hibb's  and 
Dr.  Albee's  operation  as  to 
the    ultimate    result.    In    the 

i         _.         f    +\        I             |...     ,     p.  Fig.  425. — After  retracting  the  skin  and  fat, 

nanas    01    tne    less    Skilled,    Dr.  ^he  incisi0n  is  made  in  the  median  line  or  slightly 

Albee's   Operation   is   a   simpler  to  the  side  through  the  ligament,  the  spines  and 

onp  the  interspinous  ligament.     Albee  operation. 

When  there  are  signs  of  paralysis  in  the  leg,  neither  of  these  operations 
should  be  done  until  the  spine  has  been  hyperextended  and  undergone 
treatment  to  relieve  the  pressure  on  the  spinal  cord.  When  the  nec- 
essary relief  has  been  obtained  and  the  muscular  strength  has  been  re- 
turned in  the  legs,  the  operator  then  may  select  the  operation  best 
suited  to  the  individual  case.  In  children  that  live  near  enough  to  report 
for  observation,  brace  and  jacket  treatment  are  preferable  to  the  opera- 
tion. Where  the  deformity  is  increasing  or  the  children  are  apt  to  be 
neglected  or  live  so  far  off  that  they  cannot  report  frequently  enough 
for  observation,  then  a  plastic  operation  on  the  spine  is  often  advisable. 
In  adults  an  operation  is  preferable  to  jacket  or  brace  treatment  as  it 
materially  shortens  the  disability  and  the  course  of  disease  and  enables  the 


280 


TECHNIQUE  OF  OPERATIONS 


patient  to  go  to  work  in  a  comparatively  short  time.  In  children,  appara- 
tus treatment  will  not  interfere  with  their  going  to  school  and  being  per- 
fectly well.  In  adults  the  discouragement  and  debility  following  the 
lack  of  work  is  so  discouraging  that  an  early  operation  should  be  done 
especially  if  there  is  no  paralysis.  Where  paralysis  is  beginning,  re- 
cumbent treatment  should  be  used  until  recovery  has  been  made  and 
then  an  operation  performed. 

321.  Operation   for   Obtaining   Ankylosis   of   the    Spine.      Albee 
Operation. — The    patient    is    brought    into    the    operating   room   on 

a  Bradford  frame,  lying  in 
a  posterior  plaster  shell 
which  has  been  made  sev- 
eral days  before  and  which 
holds  the  spine  in  the  posi- 
tion which  the  operator 
wishes  the  spine  to  be  after 
operation.  This  plaster 
should  not  only  have  been 
made   several    days   before 

Fig.  426. — The  spines  and  inter-spinous  ligaments  are    bu£  shou]c|  be  tried  On  and 
split.    Albee  operation. 

found  to  be  comfortable  before 
using  it  at  the  time  of  opera- 
tion. The  patient  is  put  on 
the  operating  table  and  when 
anaesthetized  is  turned  on  his 
abdomen.  The  surgeon  marks 
lightly  on  the  skin  with  a  scalpel 
the  upward  and  the  lower  limit 
of  the  spine  to  be  immobilized. 

An    incision   is   made   slightly        Fig.    427.— A  probe  is   used    to    measure    the 
above     and     extending    slightly    shape   and  length  of  the  desired  graft.     Albee 

below  these  marks.  The  incision  °Peration- 

should  be  one-half  inch  to  the  side  of  the  spinous  processes  and 
parallel  to  them.  It  is  carried  vertically  through  the  skin  and  sub- 
cutaneous fat.  This  is  retracted  exposing  the  spinous  process  (see 
figure  424).  These  are  incised  through  their  middle  with  an 
osteotome  so  that  they  are  split  continuously  with  the  spinous  and 
inter-spinous  ligaments  (see  figures  425  to  427).  When  the  space 
between  the  bone  and  inter-spinous  ligaments  is  completed  and  retracted, 
the  operator  uses  a  probe  to  measure  the  length  of  the  graft  necessary 
and  bends  the  probe  to  the  shape  of  the  cavity.  The  back  is  covered 
with  a  sterile  towel.  The  knee  is  flexed  about  35  degrees  beyond  right 
angle  and  the  ankle  held  by  an  assistant. 

An  incision  is  made  1"  to  the  outer  side  of  the  ridge  of  the  tibia.    The 
incision  is  made  rapidly  through  the  skin  and  fat  down  to  the  tibialis 


MISCELLANEOUS  OPERATIONS 


281 


anticus  muscle.  The  skin  and  fat  are  dissected  up  rapidly  exposing  the 
tibia.  The  length  and  shape  of  the  graft  is  again  measured  with  a  flexi- 
ble probe  deep  down  in  the  incision  through  the  spinous  process.  The 
operator  places  the  probe  on  the  periosteum  of  the  tibia  and  cuts  an  out- 
line on  the  periosteum  corresponding  to  the  curve  and  length  of  the  graft 
desired.  It  is  as  well  to  cut  the  graft  about  1"  longer  than  is  necessary. 
The  graft  is  cut  by  a  mechanical  saw  or  a  sharp  osteotome.  Just  before 
removing  the  graft  from  the  bone,  the  operator  uncovers  the  incision 
over  the  spine  and  makes  sure  that  it  is  ready  to  receive  the  graft  from 


A        £ 

Fig.  429. — Method  of  sawing 


Fig.   428. — The  graft  is   placed  between  the  split 
bone  and  the  split  ligaments. 

the  tibia  (see  figures  427  and  428).  The 
graft  is  then  placed  between  the  split  spinous 
processes  for  the  full  length  of  the  incision. 
By  cross  cuts  in  the  graft  (see  figure  429), 
it  may  be  curved  to  fit  any  angle.  The 
periosteum  is  sutured  firmly  over  the  graft 
with  interrupted  chromic  catgut  sutures 
number  1  or  kangaroo  tendon  (see  fig- 
ure 430).     The  operator   should  SUture   one    slots  in  a  graft  used  when  neces- 

end  and  work  np  toward  the  other.    The  S&Tl'sSSS'fb.  *S 

periosteum  should  not  be  everted  or  inverted   sawed  through.    B,  Shows  the 
as  is  often  the  case.    When  the  periosteum   possibility  of  bending  the  graft 

,  ,      ,  ,  i  ,  ,  ,     .         so  that  it  will  fit. 

and  muscle  layers  have  been  brought  to- 
gether with  interrupted  chromic  catgut,  the  muscles  on  either  side 
may  be  folded  over  and  held  by  interrupted  chromic  catgut  sutures 
number  0  over  this,  the  fat  is  sutured  with  interrupted  chromic  catgut 
and  the  skin  with  continuous  chromic  catgut.  When  the  skin  is  closed, 
two  large  pads  of  sterile  sheet  wadding  are  placed  one  on  each  side  of  the 
incision  (see  figure  431).  A  small  strip  of  sheet  wadding  is  placed  over 
the  pads.  The  plaster  shell  is  now  placed  on  top  of  the  patient,  the 
padding  well  adjusted,  a  swathe  is  placed  under  the  patient  and  passed 
around  the  plaster  shell  holding  it  firmly  in  place.  The  patient  is  then 
rolled  on  his  back  with  the  plaster  shell  in  place.  A  Bradford  frame  is 
brought  to  the  side  of  the  operating  table  on  a  truck.  The  patient 
should  be  disturbed  as  little  as  possible  for  five  days.    In  using  the  bed 


_>vj 


TECHNIQUE  OF  OPERATIONS 


pan,  the  Bradford  frame  may  be  raised  without  disturbing  the  patient 
in  the  shell.  As  a  rule  no  dressing  is  necessary  until  the  third  or  fourth 
week.  In  some  instances  a  window  is  cut  out  in  the  posterior  shell  at 
the  time  it  is  made  to  allow  dressing  without  disturbing  the  patient.  At 
i  he  end  of  six  weeks  a  plaster  jacket  or  a  brace  is  applied  and  the  patient 

allowed  to  sit  up  in  bed.  The 
patient  is  gradually  gotten  up 
and  allowed  to  walk.  At  the 
end  of  six  months  the  ap- 
paratus may  be  discarded. 

322.  Operation  for  Obtain- 
ing Ankylosis  of  the  Spine. 
Hibbs  Operation.  —  The  pa- 
tient is  brought  into  the 
operating  room  on  a  Brad- 
Fig.  430.— Sutures  are  placed  holding  the  graft  ford  frame  lying  in  a  posterior 

?ew;;^,otld;;i!^f;™ti"plr3areplaced  p^  **  •»**  has  been 

made  several  days  before  and 
which  holds  the  spine  in  the 
position  which  the  operator 
wishes  the  spine  to  be  after  the 
operation.  This  plaster  should 
not  only  have  been  made  sev- 
eral days  before  but  should  be 
tried  on  and  found  to  be  com- 
fortable before  using  it  at  the 
time  of  operation.  The  patient 
is  put  on  the  operating  table 
and  when  anaesthetized  is 
turned  on  his  abdomen.    The 


Fig.  431. — Folded  sterile  sheet  pads  are  placed  on 
either  side  of  the  incision. 


surgeon  marks  lightly  on  the  skin  with  a  scalpel  the  upward  and  the 
lower  limit  of  the  spine  to  be  immobilized. 

An  incision  is  made  slightly  above  and  extending  slightly  below  these 
marks.  The  incision  should  be  carried  vertically  through  the  skin  and 
subcutaneous  fat  one-half  inch  to  the  side  of  the  spinous  processes  and 
parallel  to  them.  This  is  retracted ;  the  operator  now  incises  the  perios- 
teum over  the  spinous  process  down  to  the  tips  of  the  bone  from  one  end 
of  the  incision  to  the  other.  This  incision  is  carried  through  the  inter- 
spinous  ligament  continuously  with  the  periosteum  which  is  to  be  re- 
moved from  either  side  of  the  spinous  process.  In  other  words,  the  peri- 
osteum is  removed  from  the  tip  of  the  spinous  process  down  on  either 
side  of  the  process  continuously  with  half  of  the  inter-spinous  liga- 
ments. The  periosteum  on  the  upper  and  under  surface  of  the  spinous 
process  is  removed  at  the  same  time.  The  dissection  is  carried  well 
forward  freeing  the  lamina  on  both  sides.  The  operation  is  done  satis- 
factorily when  the  operator  can  clear  the  periosteum  on  both  sides  con- 


MISCELLANEOUS  OPERATIONS 


283 


tinuously  with  the  ligaments,  separating  the  periosteum  from  the  liga- 
ments hardly  at  all.  The  tip  of  each  spinous  process  is  carefully 
inspected  to  see  that  it  is  denuded  of  periosteum.  The  under  side  and 
the  upper  side  of  the  spinous  process  are  also  carefully  inspected  and 
cleared  again,  if  necessary,  of  any  remaining  bits  of  periosteum.  The 
lateral  articulations  are  curetted.  The  spinous  processes  are  then  cut 
at  their  bases  and  bent  down  so  that  the  tip  of  each  spinous  process 
above  touches  the  cut  base  of  the  spinous  process  below  (see  figure  432) . 
There  is  then  a  continuous  bony  ridge  made  by  the  touching  of  the  cut 
base  of  one  spine  and  the  fresh  tip  of  the  next  process  from  one  end  of 
the  incision  to  the  other.  Small  portions  of  the  lamina  which  have 
been  denuded  of  periosteum  may  be  split  off  and  folded  across  to 
the  lamina  above  and  below.  The  periosteum  and  ligaments  which 
were  removed  en  masse  from  the  two  sides  of  the  spinous  process  are 
now  brought  together  covering  the  bone  completely.      Heavy  chromic 


(JUls) 
Fig.  432, 


-Method   of   cutting   and   overlapping   the   spinous   processes. 
Hibbs  operation. 


catgut  sutures  or  kangaroo  sutures  are  used  to  bring  these  tissues  to- 
gether. The  deep  tissues  are  brought  together  with  interrupted  chro- 
mic catgut  sutures  number  00,  the  subcutaneous  fat  with  interrupted 
chromic  catgut  sutures  number  00,  the  skin  with  continuous  chromic 
catgut.  Certain  precautions  are  necessary  in  this  operation.  There 
is  a  good  deal  of  ooze  from  the  bone  but  practically  no  bleeding  of 
any  consequence  if  the  operator  is  careful  to  make  his  dissection  with 
a  large  and  a  small  osteotome  so  that  the  work  is  done  subperiosteally. 
The  operator  should  clear  one  side  of  the  spine  working  from  above 
downward  or  from  below  upward  and  then  clear  the  other  side.  In 
doing  this  as  he  goes  downward  large  strips  are  packed  between  the 
periosteum  and  the  denuded  spine.  This  will  stop  the  bone  ooze.  The 
operator  denudes  the  spinous  process  with  the  ligaments  attached  to  the 
periosteum  all  in  one  piece.  Strips  are  packed  and  then  he  works  down- 
ward to  the  end  and  then  he  works  upward  packing  the  space  he  leaves, 
and  uncovering  the  way  he  is  going,  working  off  the  periosteum  and  the 
ligaments  deeper  and  further  forward.  With  each  succeeding  step  the 
operator  will  see  more  clearly  the  outlines  of  the  spines  and  lami- 
nae.     Having  cleared  one  side  of  the  spine  well  forward,  the  sperator 


284  TECHNIQUE  OF  OPERATIONS 

parks  the  space  between  the  periosteum  and  the  spine  with  strips  and 
works  on  the  other  side  of  the  spine.  In  bringing  together  the  periosteum 
over  the  bent  down  spinous  processes,  the  periosteum  and  muscles,  es- 
pecially in  adults  where  they  are  large,  will  be  found  to  be  rolled  in.  It 
is  important  to  unroll  the  mass  of  periosteum  and  muscles  to  which  it  is 
attached  before  placing  the  sutures  in  order  to  be  sure  that  the  removed 
periosteum  comes  again  in  contact  with  the  bone.  When  the  skin  is 
closed  two  large  pads  of  sterile  sheet  wadding  are  placed  one  on  each  side 
of  the  incision  (see  figure  431).  A  small  strip  of  sheet  wadding  is  placed 
over  these  pads,  the  plaster  shell  is  now  placed  on  top  of  the  patient,  the 
padding  well  adjusted,  a  swathe  is  placed  under  the  patient  and  passed 
around  the  plaster  shell  holding  it  firmly  in  place.  A  Bradford  frame  is 
brought  to  the  side  of  the  operating  table  on  a  truck,  the  patient  and  shell 
are  rolled  over  so  that  the  patient  lies  in  the  shell  on  the  frame.  The 
patient  should  be  disturbed  as  little  as  possible  for  five  days.  In  using 
the  bed  pan,  the  Bradford  frame  may  be  raised  without  disturbing  the 
patient  in  the  shell.  As  a  rule  no  dressing  is  necessary  until  the  third 
or  fourth  week.  In  some  instances  a  window  is  cut  out  in  the  posterior 
shell  when  it  is  made  to  allow  dressing  the  wound  without  disturbing  the 
patient.  At  the  end  of  six  weeks  a  plaster  jacket  or  a  brace  is  applied 
and  the  patient  allowed  to  sit  up  in  bed.  The  patient  is  gradually 
gotten  up  and  allowed  to  walk.  At  the  end  of  six  months  the  apparatus 
may  be  discarded. 

323.  The  Carrell-Dakin  Technique  for  the  Treatment  of  Suppura- 
tive Cases,  Compound  Fractures,  Etc.  The  use  of  the  Dakin 
solution  (Desfresne  modification)  has  improved  remarkably  in  the 
method  of  treating  not  only  deep  but  superficial  suppuration  both 
recent  and  advanced.  Recent  wounds  may  be  sterilized;  pus  cavi- 
ties and  old  infected  compound  fractures  are  made  clean  in  a  very 
short  time.  Superficial  pus  cavities  are  clean  enough  for  suture 
in  from  four  to  fifteen  days.  Deep-seated,  badly  infected  wounds 
or  extensive  neglected  compound  fractures  requiring  amputation  may 
be  rendered  clean  and  healthy  in  from  fifteen  to  twenty-five  days 
without  amputation.  In  seven  days  there  is  usually  a  very  marked 
improvement.  A  record  of  the  severity  of  the  infection  is  made 
by  making  smears  from  various  parts  of  the  wound.  These  are  taken 
daily,  stained  with  any  stain  such  as  methylin  blue  put  under  a  one- 
twelfth  oil  emersion.  The  bacteria  are  counted  regardless  of  kind. 
They  are  at  first  innumerable.  In  seven  days  they  are  usually  tremen- 
dously reduced.  When  they  amount  to  two  or  three  organisms  to  four 
or  five  fields  and  remain  so  for  five  days,  the  wound  may  be  sutured 
and  heals  by  first  intention.  This  is  the  result  in  the  worst  of  war 
wounds  treated  by  this  method.  Death,  amputation  and  prolonged 
suffering  are  all  greatly  reduced.  All  surgeons  should  become  familiar 
not  with  the  principles  but  the  exact  detail  of  this  technique.  The 
result  in  any  given  case,  it  is  estimated,  is  that  the  solution  counts  20 


MISCELLANEOUS  OPERATIONS  285 

per  cent  and  observance  of  the  technique  80  per  cent.  The  detail  is 
most  important,  first  in  the  making  and  preserving  of  the  solution; 
second,  in  the  treatment  of  the  wound,  making  large  open  cavities 
which  can  be  dressed  advantageously  by  this  method  following  the 
removal  of  all  foreign  material  or  destroyed  tissues  excepting  bone; 
third,  the  technique  in  the  care  of  the  skin  about  the  wound,  and  of  the 
wound  itself;  and  fourth,  the  closure  of  the  wound,  whenever  possible, 
at  the  proper  time.  Cases  that  would  require  from  three  to  six  months 
to  heal  can  be  healed  in  from  four  to  six  weeks,  often  in  much  less  time. 

(a)  The  Dakin  Solution  *  (Desfresne  Modification). 

The  solution  is  made  up  of  sodium  hypochlorite  free  from  caustic 
alkali  containing  0.45  to  0.50  per  cent  hypochlorite.  Under  0.45  per 
cent  is  too  weak.  Above  0.50  per  cent  is  irritating.  It  must  not  be 
heated,  not  placed  with  alcohol,  not  used  in  the  eye,  nor  intravenously. 

(b)  Preparation  of  the  solution. 

With  chloride  of  lime  (bleaching  powder)  having  25  per  cent  of  active 
chlorine,  to  make  10  litres  of  solution;  the  quantities  are  as  follows: — 

200  grams  chloride  of  lime 

25  per  cent  active  chlorine 
100  grams  sodium  carbonate 

dry  (soda  of  Solway) 
80  grams  sodium  bicarbonate,  dry. 

These  ingredients  are  put  in  a  12-litre  flask  as  follows : — 
5  litres  of  water  and  200  grams  of  chloride  of  lime,  shake  vigorously 
until  no  parts  float  and  all  is  dissolved;  leave  from  six  to  twelve  hours. 
At  the  same  time  dissolve  in  5  litres  of  ordinary  cold  water  the  car- 
bonate and  bicarbonate  of  soda.  Let  this  stand  from  six  to  twelve 
hours.  After  twelve  hours  the  soda  solution  is  poured  into  the  solution 
of  chloride  of  lime;  shake  vigorously  a  few  minutes.  Allow  the  cal- 
cium carbonate  to  be  precipitated ;  in  half  an  hour,  siphon  the  liquid  and 
filter  it  with  a  double  blotting  paper,  to  obtain  a  good  clear  liquid.  The 
stock  solution  is  kept  in  blue  and  brown  bottles  well  corked.  It  should 
be  kept  tight,  kept  cool  and  in  the  dark. 

(c)  Testing  the  chloride  of  lime  for  chlorine. 

This  must  be  done  every  time  a  new  product  is  received.  To  deter- 
mine the  active  chlorine  in  the  bleaching  powder,  titration  of  the  chlo- 
ride of  lime  must  be  done.  Take  small  quantities  from  different  parts 
of  the  jar  of  bleaching  powder,  weigh  out  20  grams,  mix  in  one  litre  of 
tap  water,  leave  in  contact  a  few  hours; 

Take  10  cu.  c.  m.  of  the  clear  liquid,  add  to  it 

10  cu.  c.  m.  of  a  10  per  cent  solution  of  potassium  iodide 
2  cu.  c.  m.  of  acetic  acid. 

*  Surgery,  Gynaecology  and  Obstetrics,  Volume  XXIV,  Number  three,  March, 
1917,  page  255.  Dr.  Sherman's  article  has  been  freely  quoted  in  obtaining  the  data 
for  the  solution. 


286  TECHNIQUE  OF  OPERATIONS 

Put  into  this  mixture,  drop  by  drop,  a  decinormal  solution  of  hyposul- 
phite (2.48  per  cent)  until  decolorized. 

The  number  N  of  cu.  c.  m.  of  this  solution  used  multiplied  by  1775  will 
give  the  weight  N  of  active  chlorine  contained  in  100  grams  of  the  speci- 
men of  chloride  of  lime. 

(d)  Making  the.  solution  with  other  chloride  of  lime  than  that  contain- 
ing 25  per  cent  of  chlorine. 

It  will  be  necessary  to  reduce  or  enlarge  the  proportion  contained 
in  the  preparation.  This  is  done  by  multiplying  the  three  numbers, 
above  mentioned,  200,  100  and  80  by  the  factor  25  N,  in  which  N  repre- 
sents the  weight  of  the  active  chlorine  per  cent  in  100  grams  of  the 
chloride  of  lime  used. 

(e)  Testing  the  Dakin  solution  for  the  amount  of  hypochlorite  of  soda 

it  contains. 
Titration  of  the  Dakin  solution: — 

measure  10  cu.  c.  in.  of  the  solution 

add  20  cu.  cm.  of  potassium  iodide  10  per  cent  solution 

20  cu.  c.  m.  of  potassium  iodide  10  per  cent  solution 
2  cu.  c.  m.  of  acetic  acid 

Drop  by  drop  add  a  decinormal  solution  of  sodium  hyposulphite  until 
decolorized. 

The  number  of  cu.  c.  m.  used  multiplied  by  0.03725  will  give  the  weight 
of  the  hypochlorite  of  soda  contained  in  100  cu.  c.  m.  of  the  solution. 
It  should  contain  from  0.45  to  0.50  per  cent  of  hypochlorite  of  soda. 
Under  0.45  per  cent  it  is  too  weak,  over  0.50  per  cent  it  is  irritating  or 
burns  the  skin. 

(f)  Testing  the  alkalinity  of  the  Dakin  solution. 

Pour  20  cu.  c.  m.  of  the  solution  and  drop  on  the  surface  of  the  liquid 
a  few  centigrams  of  powdered  phenol  phthalein.  The  correct  solution 
does  not  give  any  color. 

Lebarrague's  solution  and  Eau  de  Javel  will  give  an  intense  red  color, 
showing  in  these  two  solutions  the  presence  of  caustic  alkali. 

(g)  Difficulties  of  the  Dakin  solution. 

Unstableness  of  the  bleaching  lime  varying  in  active  chlorine  from 
15  per  cent  to  37  per  cent  which  gives  some  trouble  in  making  the  solu- 
tion. Much  of  the  sodium  bicarbonate  is  really  sodium  carbonate, 
making  it  difficult  to  neutralize  the  solution.  If  it  is  alkaline  or  caustic 
it  will  burn  the  skin  and  irritate  the  tissues.  It  must  be  neutralized  by 
sodium  bicarbonate.  It  must  be  frequently  and  thoroughly  tested  on 
account  of  its  unstableness  and  tendency  to  become  caustic.  It  must 
be  from  0.45  to  0.50  per  cent  hypochlorite; — more  makes  it  burn  and 
irritate,  less  makes  it  too  weak. 

(h)  Solutions  similar  to  the  Dakin  solution, — more  stable  but  not  yet 
proved  to  be  as  good. 

Chloramine  (Boots)  and  chlorazene  (Abbott) — paratoluene  sodium 


MISCELLANEOUS  OPERATIONS 


287 


sulpho  chloramide.    This  contains  chemically  combined  chlorine  acting 
similarly  to  Dakin's  solution.     It  is  more  stable  and  will  perhaps  be 
found  more  satisfactory  where  there  is  no  facility  for 
making  the  Dakin  solution,  or  in  hot  climates, 
(i)  First  aid  dressing  of  the  wound. 

The  skin  should  be  painted  with  iodine,  3-}4  per 
cent,  at  the  trenches,  or  where  wounded.  The  Dakin 
solution  should  be  injected  into  any  small  wound. 
If  wide  or  open,  the  wound  should  be  packed  loosely 
with  gauze  and  filled  with  the  Dakin  solution, 
(j)  Operation. — Preparation  of  the  wound  for  treat- 
ment. 

As  soon  as  the  condition  of  the  patient  allows  he  is 
anesthetized.  Free  incisions  and  explorations  are 
made  for  foreign  bodies  of  all  wounds  as  early  as  pos- 
sible. X-rays  are  taken  beforehand,  if  possible. 
The  shell  tracts  are  opened  and  any  devitalized  tissue 
excised.  Carrell  tubes  (see  figure  434)  are  placed  to 
the  bottom  of  the  cavities;  gauze  is  placed  loosely  be- 
tween the  tubes.  The  solution  is  injected  into  the  fig. 
wound  to  see  the  amount  necessary  to  fill  the  cavity  for  containing  Carreil- 
with  the  gauze  in  place.  The  surgeon  should  see  that  £££  stoker.11  ^ 
it  flows  readily  to  all  parts.  The  actual  contact 
of  the  solution  with  all  of  the  tissues  is  vital  to  its  success.  More- 
over, the  wounds  should  be  made  so  large  and  accessible  to  every 
part  that,  not  only  the  tubes,  but  the  gauze  may  be  removed  every 
twenty-four  hours  and  fresh  gauze,  or  gauze  and  tubes  easily  replaced 
to  the  remotest  corner  with  little  pain,  using  dressing  forceps  only. 
The  strictest  asepsis  is  essential  in  dressing  the  wounds. 

Over  the  dressing  is  placed  a  non- absorbent  cotton  pad  but  before 
this,  gauze  saturated  in  liquid  vaseline,  and  sterilized,  is  placed  on  the 
skin  around  the  wound.  This  is  done  to  protect  the  bed  and  clothing 
from  the  bleaching  and  destruction  of  the  chlorine.  The  whole  leg  is 
bandaged  with  non-absorbent  cotton,  or  Turkish  toweling, 
(k)  Dressing  and  after  care. 

Every  two  hours  night  and  day  the  wound  is  saturated  with  the  solu- 
tion. The  amount  used  is  carefully  noted  on  the  graduated  vessel  at 
the  head  of  the  bed.  The  necessary  amount  is  noted  and  prescribed. 
The  dressing  should  be  saturated,  as  noted  at  the  time  of  operation. 
If  there  is  pain  the  vessel  should  be  lowered.  When  the  dressing  is 
done,  the  gauze  is  changed  and  fresh  sterile  gauze  is  placed  in  the  wound 
around  the  tubes.  The  gauze  is  placed  loosely  and  must  not  occlude 
the  tubes,  or  press  or  bend  them.  It  should  not  be  dragged  on  the 
skin,  or  touched  with  the  hands;  for  this  reason  the  wound  must  be 
made  very  large  and  wide  open  at  the  time  of  operation.  The  remotest 
corners  must  be  carefully  cared  for  and  the  tubes  arranged  to  reach 


288  TECHNIQUE  OF  OPERATIONS 

every  part  of  the  cavity.  In  large,  or  small,  superficial  wounds,  the 
tubes  are  laid  lengthwise.  Either  dressing  or  artery  forceps  may  be 
used,  but  the  hands  should  not  touch  the  wound,  gauze  or  any  material. 
When  the  tubes  and  gauze  arc  arranged  in  the  wound,  a  measured 
amount  of  the  Dakin  solution  is  allowed  to  saturate  the  wound  and  the 
amounted  noted.  The  skin  is  cleaned  with  ether,  a  neutral  sodium  oleate 
is  applied  over' the  skin,  followed  by  sponging  with  the  Dakin  solution, 
and  then  the  sterile  gauze  containing  vaseline  is  applied  over  it  around 
the  wound.  Over  this  is  placed  the  chy  non-absorbent  cotton  about 
3  c.  m.  in  thinkness. 

The  dressing  is  done  ever3r  twenty-four  hours  but  in  emergency,  may 
go  two  or  three  days.  The  saturation  with  the  Dakin  solution  must 
be  continued  every  two  hours,  night  and  day.  The  intermittent  satu- 
ration seems  to  be  more  satisfactory  than  a  constant  drip.  It  takes  at 
least  two  weeks  to  master  the  details  of  this  technique.  Re-infection 
is  easy,  and  may  come  from  lack  of  care  of  the  skin,  or  the  failure  to 
observe  any  detail. 
(1)  [Microscopic  examination  of  wound  smears. 

A  one-twelfth  oil  emersion  is  used.  Smears  are  prepared  in  the  usual 
way  and  stained  with  almost  any  simple  stain.  For  the  first  six  days 
enormous  numbers  of  organisms  are  present  and  enormous  numbers  of 
polymorphonuclear  leucocytes.  After  the  seventh  day,  the  organisms 
decrease  markedly,  small  mononuclears  appear  instead  of  the  poly- 
morphonuclears. The  appearance  of  macrophages  after  the  tenth  or 
eleventh  day  is  considered  a  very  good  sign.  The  bacteria  constantly 
decrease,  the  cocci  remaining  the  longest.  When  there  are  but  two  or 
three  bacteria  in  five  fields  and  this  condition  persists  for  five  clays  con- 
secutively the  wound  may  be  sutured  and  heals  by  first  intention.  It 
is  said  to  be  safe  to  do  a  bone  graft  two  weeks  after  the  wound  is  healed. 
It  is  probably  better  to  wait  two  months. 

The  solution  is  non-toxic  regardless  of  the  amount  used,  it  will  abort 
infection,  and  control  well  established  suppuration.     Its  success  de- 
pends upon  the  Carrell  detail, 
(m)  The  apparatus  and  material  neces- 
sary.    (See  Figs.  433  to  435.) 
(1)  A  vessel  for  containing  the  solution. 
The  vessel  is  suspended  three  feet  above 

Fig.  434,-RubbeT  tubes~from  the  patient.  It  should  be  graduated  and 
the  wound  are  attached  to  a  glass  empty  not  at  the  side  but  at  the  bottom, 
distributor.  s0  that  it  may  all  be  emptied.    It  should 

be  closed  with  a  rubber  cork  through  which  a  glass  thistle  (E,  figure 
No.  433)  is  fitted,  with  sterile  cotton  in  its  end.  In  this  way  the  air  may 
enter  but  no  chlorine  is  apt  to  escape. 

(2)  The  tubing  should  be  pure  gum  rubber  to  withstand  the  chemical 
action  of  the  solution,  five  millimeters  in  diameter,  one  millimeter 
thick,  making  the  internal  diameter  three  millimeters.    It  is  cut  from  15 


MISCELLANEOUS  OPERATIONS  281) 

to  25  c.  m.  long.  The  tubes  should  be  good  enough  rubber  so  that  it 
may  be  tied  with  pagenstecher  at  its  distal  end  and  not  leak.  The  tube 
is  perforated  at  its  distal  end  with  a  leather  punch  through  both  walls 
at  once.  The  holes  should  be  every  l->^  millimeter,  six  to  ten  pairs  of 
punctures  in  all.  The  holes  at  one  level  are  at  right  angles  to  those 
above  and  below.    All  of  the  plugs  should  be  removed. 

(3)  A  glass  drip  (C,  figure  No.  433)  similar  to  that  used  for  rectal 
salt  solution  is  fastened  to  the  rubber  outlet  pipe  from  the  Dakin  solu- 
tion.   This  should  be  six  millimeters  in  diameter. 

(4)  Distributors  of  glass  (A  &  B,  figure  No.  435)  so  that  one,  two  or 
four  tubes  may  be  attached  to  each  distributor.  The  distributors  are 
attached  to  the  numerous  tubes  in  the  wound,  one  end 
being  reserved  for  the  supply  tube  to  which  the  glass  a__. 
drip  is  attached  with  a  regulator  clamp  above  it.  The  u  A 
bottle  is  placed  three  feet  above  the  patient.  «     r— i~n^ 

(5)  A  regulator  clamp  attached  above  the  glass         U    Li  LI  U 
drip.     (D,  figure  No.  433.)  FlG-  435. -Other 

(6)  Gauze  soaked  in  liquid  vaseline  and  sterilized;  tributors  wfth^woor 
then  cool.  This  is  used  around  the  skin  to  prevent  three  or  more  open- 
leaks.  ings- 

(7)  Sterile  gauze  to  pack  lightly  in  the  wound  and  to  use  in  the  dress- 
ing. 

(8)  Non-absorbent  cotton  to  envelop  the  limb  and  to  place  over  the 
sterile  gauze  used  in  the  dressing. 

(9)  Ether  to  wash  the  skin  about  the  wound. 


CHAPTER   II 


PLASTER    OF    PARIS    AND    BRACES 


i 


324.  The  Application  of  Plaster  of  Paris  Bandage. — Plaster  of  Paris 
bandages,  three,  four  and  five  inches  wide  are  more  useful  than  any 
other  sizes.  While  applying  a  plaster  the  water  should  be  frequently 
changed,  a  bucket  full  for  every  eight  plasters.  The  water  becomes 
super-saturated  after  that. 

Sheet  wadding  rollers  should  be  made  three  or  four  inches  broad  and 
rolled  one  thickness  at  a  time.  In  this  way  they  may  be  placed  in  close 
position  to  the  patient  and  rolled  snugly,  making  the  outlines  of  the  body 
distinct.  This  is  essential  in  dealing  with  deformities.  It  is  impos- 
sible to  apply  a  well  fitting  plaster  over  carelessly  ap- 
plied sheet  wadding.  The  leg  should  look  like  a  leg, 
the  arm  like  an  arm  after  the  application  of  sheet  wad- 
ding. A  liberal  amount  of  snugly  fitting  sheet  wadding 
should  be  used.  A  plaster  of  Paris  bandage  should  be 
light,  re-enforced  when  necessary  at  certain  places. 
Deformities  and  contractures  should  be  over  stretched 
and  the  joints  returned  so  nearly  to  normal  at  the  end 
of  the  operation  that  no  force  will  be  necessary  during 
the  application  of  the  plaster.  Heavy  plasters  are 
necessary  after  operations  on  the  hip  in  heavy  patients 
to  allow  them  to  be  moved  without  breaking  the  plas- 
ter. Such  plasters  should  be  heavy  where  they  are 
apt  to  break;  the  re-enforcement  is  made  by  plaster 
ropes. 

In  making  plaster  ropes,  the  end  of  the  soaked  plas- 
ter bandage  is  held  in  one  hand  and  the  bandage  un- 
rolled to  the  length  desired.    This  length  is  measured 
off  repeatedly  over  and  over  until  the  bandage  is 
The  operator  holds  between  his  hands  the 

This  is 


Fig.     4 3  6.  —  A 

method  of  lacing  a 
plaster  of  Paris 
jacket  or  leg  plaster. 
Holes  are  made  one 
or  one-half  inches  to    Used  Up 

two  inches  from  the  plaster  bandage  unrolled  the  length  desired 

r  passed  through  his  closed  hand  and  squeezed  firmly  to- 
gether into  the  shape  of  a  rope.  In  doing  this  all 
parts  of  this  plaster  bandage  come  firmly  in  contact. 
The  rope  is  then  applied  while  it  is  soft  and  pliable 
to  the  plaster  on  the  patient  at  the  point  where  re- 
needed.     The    operator    flattens    the    rope   into    the 


three  inches  apart. 
Raw  hide  or  heavy 
cord  is  passed 
through  the  loops. 
(See  figures  461  to 
464.) 

enforcement 


is 


plaster  leaving  it  round  wherever  it  is  used  to  bridge  over  a  space. 
Plaster  bandages  are  applied  over  the  rope,  incorporating  it  in  the 
plaster.     The  plaster  should  be  split  on  both  sides  shortly  after  the 

290 


PLASTER  OF  PARIS  AND  BRACES 


291 


Fig.  437. — Another 
heavy     cord     is     run 


Fig.  438.  —  Both 
cords  are  tightened 
and  tied  at  each 
end. 


operation  and  strapped  on  with  webbing  straps  and  buckles  or  with 
adhesive  straps  or  tied  with  a  wet  bandage.  A  window  should  be  cut 
over  the  incision  to  allow  it  to  be  inspected  without  disturbing  the 
plaster.  Plaster  ropes  may  be 
used  to  re-enforce  where  large 
windows  are  necessary  (see  fig- 
ures 450  to  460).  If  there  is 
much  swelling,  the  plaster  is 
loosened  and  the  front  half 
lifted  so  that  the  finger  may 
be  passed  between  the  halves 
from  one  end  of  the  plaster  to 
the  other  on  the  sides.  If  there 
is  still  much  swelling,  the  front 
of  the  plaster  is  removed  and 
the  sheet  wadding  opened,  ex- 
posing the  skin  along  the  whole 
length  of  the  limb.  A  well 
padded  plaster  is  comfortable. 
There  should  be  no  pain  ex- 
cepting that  coming  from  the  through  the  loops  of 

"trip  first  cord 

operation.   Bone  operations  are 

rendered  very  much  less  painful  if  the  surgeon  is  careful 
in  the  manipulation  of  the  bone  and  avoids  being  rough 
when  force  is  necessary. 

325.  Lacing  a  Plaster. — When  a  plaster  is  to  be  re- 
moved and  reapplied,  a  temporary  method  of  lacing 
the  plaster  has  been  found  very  convenient  (see  fig- 
ures 436  to  440).  The  plaster  is  removed,  holes  are 
made  with  a  big  awl  two  or  three  inches  apart  one  or 
two  inches  from  the  edge  of  the 
plaster.  The  holes  should  be 
made  one-fourth  inch  in  di- 
ameter so  that  an  ordinary  shoe 
lacing  can  be  passed  through 
the  hole,  double.  A  long  cord 
or  lacing  is  placed  on  the  under 
side  of  the  plaster  (see  fig- 
ure 436)  and  loops  from  it 
Fig.  440.— A  lacing  passed  up  through  each  hole, 
is  used  from  side  to  A  second  lacing  is  passed  down 
the  outside  of  the  plaster 
through  the  loops.  The  under 
lacing  is  then  pulled  tight  holding  the  outside  lacing  which  is  also 
stretched  tight  (see  figures  438  and  439).  The  lacings  are  tied  together 
at  the  ends  of  the  plaster;  a  set  of  holes  and  two  lacings  have  been 


Fig.  439.  —  The 
cord  between  the 
holes  is  tight  but 
loosens  enough  to 
act  as  a  loop  for 
the  lacing.  (See  fig- 
ure 440) . 


side  to  hold  the  plas- 
ter together. 


292 


TECHNIQUE  OF  OPERATIONS 


r 


applied  along  each  edge.  When  the  plaster  is  reapplied  there  will  be  a 
loop  of  lacing  every  two  inches  along  each  edge.  The  loops  are  used 
as  eyelets,  an  ordinary  lacing  passed  through  them  holding  the  plaster 
together  (see  figure  440). 

326.  Plaster  of  Paris  Bandage  for  Neck  or  Head,  Neck  and  Thorax. 
Method  of  Applying  "Plaster  Ropes"  (see  figures  420  to  422). — In 
applying  a  plaster  of  Paris  for  the  head,  neck  and  thorax,  a  light  plaster 

should  be  put  on  the  thorax  and  another  on  the  head 
in  the  following  way: — sheet  wadding  and  a  stockinet 
cover  the  head  and  neck  except  the  face,  a  band  of 
plaster  connects  the  forehead  with  the  occiput,  another 
band  goes  in  front  of  the  ear  under  the  chin  and  over 
the  top  of  the  head.  A  thickness  of  felt  is  placed 
under  each  band.  The  plaster  should  avoid  the  ears. 
The  thorax  is  covered  with  sheet  wadding,  and  felt 
straps  three  inches  broad  and  twenty  inches  long  over 
each  shoulder.  Over  each  of  these  is  placed  a  flattened 
plaster  rope.  A  light  plaster  is  then  put  on  the  thorax, 
the  plaster  ropes  are  flattened  and  included  in  the 
plaster.  The  four  ends  are  turned  up  and  looped  into 
the  thorax  plaster  as  it  is  applied;  the  head  is  now 
held  in  the  desired  position,  a  plaster  rope  is  placed 
on  each  side  extending  from  the  front  of  the  thorax  up 
over  the  shoulder  rope  connecting  with  the  plaster  in 
front  of  the  ear.    A  third  extra  heavy  rope  extends 

•aciS' 44  N^the  from  the  Plaster  on  the  °™]'Pllt  to  tne  middle  of  the 
window  over  the  ab-  back  or  to  the  back  of  a  shoulder  strip.  These  ropes 
domen,  the  back  of  should  be  flattened  on  the  thorax.  They  are  made 
S'thrboltoS'ofihf  as  long  as  necessary  and  one  inch  by  one  and  one- 
sacrum.    Under  the  half  inches  broad;  the  double  rope  behind  is  twice 

arm,  the  plaster  cut    £his  size 

Trto^lLfZ  The  ropes  are  applied  when  soft  and  rubbed  well 
posterior  axillary  into  a  round  shape.  They  are  flattened  wherever  they 
line.    The  jacket  is  are  in  contact  with  plaster.    The  round  part  of  the 

vertical   at  the   an-  .  ,  -,iiji         i  i_  •   u 

tenor  axillary  line  ropes  may  be  covered  over  with  plaster  bandages  which 
and  extends  straight  are  placed  over  them  and  extend  downward  to  the 

up  to  the  clavicle.        main  part  of  the  plagter> 

327.  A  Plaster  of  Paris  Jacket. — When  a  plaster  is  applied  to  hold 
the  spine,  a  thick  undershirt  is  worn.  The  anterior  spines  and  the 
crest  of  the  ilium  should  be  well  padded  with  felt,  also  the  sacrum 
and  the  front  of  the  chest  and  axilla.  The  plaster  is  applied  over 
this  and  re-enforced  so  that  a  large  window  may  be  cut  over  the 
abdomen  (see  figure  441).  The  plaster  may  be  slit  on  the  two  sides 
and  laced  as  described  above  (see  figures  436  to  440),  or  it  may 
be  slit  in  front  and  laced  here.  If  the  plaster  is  to  be  laced  at  the  two 
sides,  in  cutting  the  plaster  two  angular  cuts  should  be  made  on  each 


PLASTER  OF  PARIS  AND  BRACES  293 

side  (see  figure  461)  in  order  that  the  sides  will  fit  and  the  plaster  not 
twist. 

The  top  of  the  plaster  should  reach  as  high  as  the  collar  bone 
in  the  middle  and  in  front  of  the  shoulder;  large  cuts  are  made  at  the 
side  for  the  arm  so  that  it  is  not  held  up  by  the  plaster.  Below,  it 
should  cover  the  whole  of  the  sacrum  behind  so  that  in  sitting  upright 
it  is  one  inch  off  of  the  chair.  In  front  it  covers  the  anterior  superior 
spine  about  one  inch  and  is  cut  up  to  allow  right  angle  flexion  of  the  hip. 

328.  The  Plaster  Cuirass. — Where  an  operation  is  performed  on 
the  shoulder  or  hip  in  a  very  heavy  person,  the  body  portion  of  the 
plaster  may  be  applied  with  a  double  swathe  posterior  and  a  plaster  of 
Paris  bandage,  anterior.  This  plaster  is  continuous  with  the  leg  or  arm 
as  the  case  may  be  and  holds  the  hip  or  shoulder. 

Plaster  cuirass  for  the  shoulder  (figures  318,  319,  320) 

The  arm  is  abducted  and  outwardly  rotated,  a  double  swathe  of  un- 
bleached cotton  passed  under  the  thorax;  this  is  slid  up  so  that  it  will 
reach  a  little  higher  than  the  clavicle.  The  swathe  is  torn  at  the  side  mak- 
ing about  eight  many  tails  (see  figure  319)  each  one  and  one-half  inches 
to  two  inches  broad.  They  should  be  torn  to  the  posterior  axillary  line  on 
either  side.  As  the  swathe  is  doubled  the  tails  are  double  making  eight 
pairs  of  tails.  Sheet  wadding  is  placed  over  the  chest  and  shoulders 
and  around  the  arm  and  hand.  A  heavy  sheet  wadding  pad  six  inches 
broad  is  placed  on  either  side  of  the  chest  from  the  axilla  down.  The 
plaster  of  Paris  is  applied  over  the  thorax  in  two  layers,  the  third  layer 
reaches  over  the  side  of  the  thorax  and  is  caught  by  a  double  many  tail 
near  the  posterior  axillary  line,  the  plaster  bandage  loop  resting  on  the 
thick  sheet  wadding  pad.  The  plaster  bandage  is  carried  to  the  oppo- 
site side  and  is  caught  there  in  like  manner;  the  bandage  is  carried  over 
the  thorax,  being  caught  on  one  side  and  the  other,  until  it  has  been 
looped  all  the  way  down  on  each  side,  around  each  of  the  double  tails. 
The  plaster  is  applied  and  re-enforced  on  the  front  of  the  thorax.  It  is 
then  looped  again  around  the  many  tails  on  either  side.  Two  layers  of 
plaster  of  Paris  are  placed  on  the  arm  and  shoulder  and  two  heavy 
ropes  of  plaster  are  made  one  inch  thick  and  two  inches  broad.  These 
are  put  along  the  arm  together  and  reach  over  the  thorax  where  they 
are  divided  like  an  inverted  Y  (figure  320)  one  down  the  front  of  the 
chest,  the  other  diagonally.  These  ropes  are  flattened  into  the  plaster. 
More  plaster  is  put  over  the  arm  and  hand  and  thorax,  finishing  the 
plaster. 

When  the  plaster  is  complete,  each  many  tail  is  pulled  through  its 
plaster  loop  (consisting  of  three  or  four  turns  of  plaster).  In  tins  way 
the  posterior  cloth  is  made  tight  and  smooth. 

The  two  upper  tails  are  placed  too  high  to  be  incorporated  in  the 
plaster  at  the  side.  They  are  brought  over  the  shoulder,  two  double 
tails,  over  each  shoulder  and  incorporated  in  loops  of  plaster  at  the  top 


294  TECHNIQUE  OF  OPERATIONS 

during  the  application  of  the  thoracic  part.  These  tails  are  now  tight- 
ened and  tied  to  each  other,  two  on  the  right  and  two  on  the  left.  At 
the  side  when  the  swathe  tails  have  all  been  tightened  on  the  right,  the 
upper  two  are  tied  to  one  from  the  next  plaster  loop,  the  other  is  tied  to 
one  from  the  next  loop  below  and  so  on  until  finally  the  lower  one  from 
the  last  loop  but  one  is  tied  to  the  two  from  the  last  loop.  On  the  left 
side  the  tails  are  now  tightened,  drawing  the  cloth  smoothly  behind. 
The  tails  are  tied  as  described  above.  In  this  way  one-half  of  each  tail 
goes  up,  the  other  half  down  to  be  tied  to  half  of  the  next  tail.  The 
last  tail  at  the  top  and  the  last  at  the  bottom  are  not  divided. 

329.  Plaster  Cuirass  for  the  Hip  (see  figures  318  to  320).— The 
thoracic,  abdominal  and  pelvic  portion  of  the  plaster  is  applied  as  de- 
scribed for  the  shoulder.  The  double  swathe  made  of  unbleached  or 
tough  cotton  reaches  over  the  buttock  upward  to  the  nipple  line.  The 
plaster  is  re-enforced  on  either  side  of  the  abdomen  and  also  across  the 
thorax  and  across  the  pubic  bone,  so  that  a  large  window  may  be  cut 
over  the  abdomen  without  weakening  the  plaster.  When  two  layers  of 
the  leg  plaster  are  applied,  four  heavy  plaster  ropes  are  made,  one  inch 
by  two  inches  broad  and  two  feet  long;  one  reaching  from  the  side  and 
nipple  line,  one  from  the  middle  front  of  the  thigh  to  the  waist,  and 
another  curving  over  the  pubic  bone,  a  fourth  from  the  middle  of  the 
thigh  in  front  to  the  extreme  side  of  the  plaster  and  reaching  to  the  waist. 
These  ropes  are  flattened  and  moulded  into  the  underlying  plaster. 
More  layers  of  plaster  are  then  put  on  the  body  plaster  and  leg  plaster 
until  it  is  completed.  These  re-enforcements  should  be  placed  so  that 
windows  can  be  made  in  the  plaster  allowing  the  incisions  to  be  dressed 
without  disturbing  the  plaster.  The  leg  portion  is  split  at  either  side 
down  to  the  toes. 

The  plaster  is  not  only  useful  for  fasciotomies  at  the  hip  and  opera- 
tions on  the  shoulder  or  hip  in  infantile  paralysis  but  in  many  other  or- 
thopedic conditions.  In  impacted  fracture  in  old  people  the  cuirass 
may  be  applied  without  disturbing  the  patient  lying  in  bed.  The  double 
cloth  is  passed  under  the  body ;  the  leg  gently  abducted  and  held  there, 
moving  the  patient  just  enough  to  have  the  leg  off  of  the  bed. 

One  assistant  holding  the  leg  or  arm  is  all  that  is  necessary  for  the 
application  of  this  form  of  plaster. 

When  a  spica  board  and  many  assistants  are  not  available,  it  will  be 
found  a  very  convenient  form  of  plaster,  especially  when  the  patient  is 
heavy.    For  any  one  used  to  handling  plaster  of  Paris  it  is  easy  to  apply. 

330.  Plaster  of  Paris  Bandage  for  the  Hip.  (See  figure  450;  see 
also  Plaster  Cuirass  for  the  Hip,  and  Congenital  Dislocation  of  the 
Hip  Plaster). — In  the  application  of  a  short  plaster  spica  the  anterior 
spines  should  be  well  padded  and  also  the  sacrum.  In  lying  down  it  is 
difficult  to  be  comfortable  unless  there  is  plenty  of  padding  over  the 
sacrum.  A  heavy  felt  pad  should  be  used  here.  About  twelve  folds  of 
sheet  wadding  are  equal  to  a  good  felt  pad. 


PLASTER  OF  PARIS  AND  BRACES  295 

Where  an  operation  has  been  done  on  the  hip  it  is  better  to  in- 
clude the  thorax  and  the  leg  and  foot  (see  figures  27  to  29).  In  ap- 
plying a  plaster  to  the  thorax  and  leg  there  should  be  felt  pads  over 
the  anterior  spines  and  sacrum  in  addition  to  the  usual  sheet  wadding 
which  is  applied  from  the  toe  to  the  axilla.  The  plaster  should  fit 
snugly  and  be  re-enforced  over  the  pubic  bone,  over  the  back  of  the  hip 
double,  over  the  front  of  the  thigh  and  hip  and  pubic  bone  and  finally 
on  either  side  and  above  the  abdomen.  These  re-enforcements  consist 
of  one  plaster  rope  one  and  one-half  inches  by  one  inch  wide.  A  large 
window  is  cut  over  the  abdomen  in  order  that  there  shall  be  no  pressure 
here.  The  plaster  is  split  at  each  side  and  held  together  by  adhesive 
or  webbing  straps.  A  short  hip  plaster  for  walking  may  be  applied 
later  on.  This  includes  the  pelvis  and  the  leg  as  far  as  the  knee.  This 
should  be  well  padded  and  may  be  made  to  lace  on  both  sides 
of  the  leg  and  both  of  the  pelvis  as  described  above  (figures  436  to 
440). 

When  a  hip  plaster  is  applied  to  hold  abduction  or  flexion  or  hyperex- 
tension,  it  is  important  that  a  few  turns  be  taken  around  the  thigh  of  the 
opposite  leg  to  make  sure  that  the  pelvic  portion  cannot  ride  up  on  that 
side.  After  ten  days  or  later  when  the  patient  begins  to  sit  up  this 
portion  of  the  plaster  is  removed. 

331.  Plaster  of  Paris  for  Congenital  Dislocation  of  the  Hip. — Fol- 
lowing the  operation  for  congenital  dislocation  of  the  hip  a  plaster  of 
Paris  bandage  is  applied  as  follows : — stockinet  or  other  suitable  cover- 
ing is  applied  to  the  pelvis  and  the  legs.  Felt  pads  are  applied  over  the 
anterior  spines,  over  the  top  of  the  trochanter,  under  the  sacrum  and 
over  the  internal  condyles  of  the  femur.  A  well  fitting  plaster  is  then 
applied  over  the  thighs  and  pelvis  for  a  double  case  or  in  a  single  case 
over  one  thigh  with  a  few  turns  over  the  other  to  prevent  the  pelvic 
portion  from  slipping  up.  Heavy  plaster  re-enforcement  or  plaster  ropes 
are  placed  in  front  over  the  pelvic  bone  (see  figures  5  to  7)  along  each 
thigh  and  in  front  to  prevent  the  breaking  near  the  anterior  spine.  A 
similar  re-enforcement  is  placed  behind  it  on  the  sacrum  and  down  the 
back  of  the  thigh  (figures  11  to  14).  More  plaster  bandages  are  used  to 
bind  this  re-enforcement  to  the  rest  of  the  plaster.  The  thigh  of  the 
dislocated  hip  or  hips  should  be  parallel  to  a  line  connecting  the  anterior 
spines  and  if  possible  the  knees  should  be  above  this  line  and  posterior 
to  it.    This  will  show  good  overcorrection. 

The  plaster  should  pull  the  trochanter  down  and  hold  it  firmly.  The 
tuberosity  of  the  ischium  should  be  held  firmly  and  be  well  padded.  When 
the  part  of  the  plaster,  including  the  pelvis  and  thigh  and  knee,  is  harden- 
ing, padding  is  applied  to  the  lower  leg  and  foot  and  the  plaster  con- 
tinued downward,  the  foot  being  held  at  right  angles. 

It  is  important  to  maintain  the  desired  position  of  the  thigh  and  have 
the  plaster  harden  immediately,  maintaining  the  Mueller  or  Lorenz 
position  while  completing  the  plaster  down  to  the  foot.    The  plaster 


296  TECHNIQUE  OF  OPERATIONS 

should  be  split  into  an  anterior  and  posterior  half  as  shown  in  figures  11 
to  14,  and  laced  as  shown  in  figures  436  to  440. 

332.  Application  of  a  Hip  Plaster  of  Paris  after  Fasciotomy.  Or 
After  Osteotomy  of  the  Hip  or  Trochanter. — It  may  be  as  well  to  go 
more  into  detail  as  to  the  application  of  plaster.  A  loose  ill-fitting 
plaster  does  not  hold  the  patient  or  the  bone.  The  sheet  wadding  should 
fit  the  leg  snugly  and  the  body  perfectly.  After  the  application,  the 
outlines  of  the  patient  should  be  distinct  and  shapely.  A  pad  of  heavy 
felt  is  placed  over  the  sacrum,  another  one  over  each  anterior  spine. 
A  thin  layer  of  felt  covers  the  chest  from  the  posterior  axillary  line 
laterally  and  reaching  down  to  the  lower  edge  of  the  ribs.  The  sheet 
wadding  should  be  applied  lavishly  but  firmly  all  over  the  patient  and  it 
should  fit  snugly.  A  large  thick  felt  pad  is  placed  over  the  tuberosity  of 
the  ischium  and  the  perineum  of  the  affected  side  (see  figure  30).  A  long 
rope  of  plaster  is  applied  over  this  felt  holding  the  felt  against  the  tuber- 
osity of  the  ischium.  This  plaster  rope  should  be  long  enough  to  ex- 
tend to  the  axilla  in  front,  to  the  axilla  behind  (see  figures  59  and  60) .  Its 
ends  are  held  by  a  nurse  during  the  application  of  the  plaster  to  the 
back.  Tins  plaster  rope  should  be  used  after  osteotomy  or  fractures 
at  the  hip.  The  plaster  is  then  applied  to  the  leg  as  far  as  the 
knee,  the  knee  being  well  padded  with  felt  in  addition  to  the  sheet 
wadding.  The  plaster  should  then  be  re-enforced  heavily  in  the 
front  of  the  leg  and  hip,  again  over  the  pubic  bone  and  front  of  the 
leg,  again  on  the  front  up  to  the  nipple.  Additional  re-enforcement 
should  be  made  on  the  side  of  the  leg  well  posterior  and  extends 
well  up  to  the  thorax.  In  a  heavy  person  each  of  these  re-enforce- 
ments should  be  one  inch  thick  and  two  inches  wide  (see  figure  28). 
Further  re-enforcement  of  plaster  is  made  across  the  front  of  the  chest, 
the  sides  of  the  abdomen  and  over  the  pubis,  marked  by  lines  (see 
figures  28  and  29) .  The  plaster  is  finished  rapidly  down  from  the  axilla 
to  the  knee  on  the  unaffected  side  and  down  about  six  inches  on  the 
opposite  thigh.  As  soon  as  the  plaster  has  hardened  the  traction  is 
removed  gently  from  each  leg.  Sheet  wadding  is  applied  around  the 
foot  and  ankle  on  the  affected  side  and  the  plaster  is  completed  from  the 
toes  to  the  knees.  The  plaster  is  cut  out  over  the  abdomen  and  behind 
as  high  as  the  upper  sacrum.  The  pelvic  portion  should  be  very  heavy. 
The  patient  should  lie  in  bed  with  the  buttocks  resting  on  the  bed  and 
the  operated  leg  off  of  the  side  on  the  bed  in  order  to  maintain  the 
hyperextended  position  of  the  hip,  unless  he  is  placed  on  a  Brad- 
ford frame  held  above  the  bed.  If  there  is  too  much  pressure  on  the 
chest,  the  leg  is  lowered.  In  this  way  there  is  no  danger  of  losing  the 
hyperextended  position  of  the  leg.  Plasters  should  be  split,  "bi-valved," 
on  both  sides  of  the  leg  and  foot  and  tied  with  a  wet  bandage  or  strapped 
with  webbing  straps  or  adhesive.  It  is  often  necessary  to  use  sedatives 
for  the  first  five  days,  when  the  correction  has  been  considerable.  They 
should  be  given  rather  than  withheld  for  pain  or  restlessness.     After 


PLASTER  OF  PARIS  AND  BRACES 


297 


five  days  a  well  padded  plaster  will  be  perfectly  comfortable.  The 
patient  lies  on  his  back  for  five  weeks  and  then  is  sat  up  in  the  original 
plaster.  In  sitting,  the  good  leg  is  flexed,  the  other  reaches  over  the 
edge  of  the  bed.  At  the  end  of  the  sixth  or  seventh  week  the  patient  is 
stood  up  a  little  at  a  time  and  finally  at  the  end  of  the  eighth  or  ninth 
week  he  walks  on  the  good  leg  with  crutches  and  assistance.  The 
plaster  is  cut  so  that  the  knee  portion  may  be  removed  posteriorly  and 
allow  a  little  motion  here.  When  he  is  able  to  stand  without  showing 
any  weakness,  the  plaster  is  removed  and  a  light  plaster  applied  with 


Fig.  442.- 


-Side  view  of  apparatus  applied  without 
elastic  bands. 


IP 


Fig.  443. — Elastic  straps  applied  to  the  hooks  of 
the  apparatus  to  overcorrect  finger  flexion,  side 
view. 


Fig.  444. — Dorsal  view  of  post-operative  ap- 
paratus to  correct  finger  flexion.  (Note  attachment 
of  elastic  bands  from  each  finger  to  the  wrist). 


Fig.  445.  —  A  finger 
splint  for  stretching  in 
hyper  extension  the 
metaearpo-phalangeal  or 
for  the  phalangeal  joint. 
The  cord  reaches  around 
the  upper  arm.  (See  fig- 
ure 446). 


the  patient  standing  and  holding  on  to  his  crutches.  This  position  is  pref- 
erable to  one  lying  down  when  the  plaster  is  to  be  used  for  locomotion. 
333.  Retaining  Apparatus  after  Operation  on  the  Hand  (442  to  446) . — 
In  claw  hand  and  deformities  of  the  finger  the  same  plaster  apparatus 
may  be  used  as  described  for  hammer  toe.  In  the  case  of  a  hand,  it  is 
more  convenient  to  use  a  wire  splint  or  aluminum  splint  with  a  point  for 
each  finger  bent  to  correct  the  deformity,  the  wrist  should  be  flexed  or  ex- 
tended and  it  should  always  include  the  flexed  elbow  in  order  to  maintain 
good  position  of  the  hand  and  wrist.  For  hyperextension  of  the  fingers 
and  wrist,  the  palm  of  the  hand  is  usually  placed  upward,  the  splint 
on  the  palm  of  the  hand.  For  flexion  of  the  fingers  and  wrist  the  palm 
is  placed  downward,  the  splint  on  the  back  of  the  hand.     This  will 


298 


TECHNIQUE  OF  OPERATIONS 


necessarily  vary  according  to  the  condition.  It  is  usually  convenient 
to  have  the  elbow  part  of  the  splint  separate  from  the  wrist  and  hand 
splint.  The  former  is  applied  to  the  arm  and  forearm,  the  latter  over- 
laps the  former  about  four  inches  in  the  forearm.     The  hand  and  finger 


Fig.  446.— Method 
of  applying  the 
string  around  the 
upper  a  r  m  when 
using  the  splint. 
(See  figure  445). 


Fig.  447. — Method  of  splitting  a  plaster  of  Paris  applied  to 
the  leg,  allowing  the  front  half  or  the  posterior  half  to  be  re- 
moved. There  is  a  window  cut  when  necessary  to  allow  in- 
spection of  the  dressing.  There  is  a  plaster  rope  flattened  so 
that  the  leg  will  not  rotate.  The  plaster  is  held  together  with 
webbing  straps.  A  knee  plaster  should  reach  high  on  the  thigh. 
(See  figure  448.) 


part  is  applied  and  then  brought  into  position  and  strapped  to  the  elbow 

splint.     In  difficult  cases  this  method  of  application  has  been  found 

very  satisfactory. 

334.  Plaster  of  Paris  Bandage  after  Operation  on  the  Knee. — In 

the  application  of  a  plaster  to  the  knee  after  operation  for  correction 

of  deformity,  the  sheet  wadding  should  fit 
perfectly.  The  plaster  should  reach  high  in 
the  groin  in  order  to  get  a  grip  on  the  upper 
end  of  the  femur,  the  plaster  should  hold 
the  lower  end  of  the  femur  snugly,  also  the 
upper  and  lower  end  of  the  tibia  and  the  foot 
and  ankle.  If  the  plaster  does  not  resemble 
the  shape  of  the  leg  after  its  application 
there  is  apt  to  be  more  or  less  motion  at  the 
knee  which  may  interfere  with  the  result  of 
the  operation.  The  knee  should  always  be 
bent  a  little  backward,  and  a  little  hyperex- 
tended  during  the  application  of  the  plaster. 


Fig.  448. — End  view  of  plas- 
ter (figure  447).  Notice  that 
the  heel  is  held  off  of  the  table. 
A   plaster   rope    flattened   pre- 

formities  at  the  knee.  In  straightening  the 
knee,  pressure  should  be  made  above  and 
Pressure  on  the  patella  maintained  by  the 
plaster  may  cause  it  to  be  adherent.  The  foot  and  ankle  are  included 
in  the  plaster  whenever  the  knee  is  sensitive  or  the  operation  has  been 
extensive.     A  plaster  rope  is  applied  around  the  finished  plaster  (see 


leg  in  bed  unnecessary. 


not  over  the  knee  cap. 


PLASTER  OF  PARIS  AND  BRACES 


299 


figures  447  and  448)  extending  on  either  side  of  the  plaster  preventing 
the  leg  from  rotating  on  the  table  or  bed.  This  rope  may  be  placed  at 
the  calf.  When  the  knee  is  exquisitely  tender,  the  plaster  should  in- 
clude the  joint  above  as  well  as  the  joint  below.  The  plaster  is  split  at 
the  sides  and  held  together  with  webbing  or  adhesive  straps  or  a  wet 
bandage  (see  figures  156  to  158).      Windows  are  cut  for  inspection  of 

the  dressing  without  disturbing 
the  joints.  Extremely  large 
windows  may  be  provided  for 
by  re-enforcement  with  plaster 
rope  (see  figure  449). 


Fig.  449.  —  Method 
of  applying  a  plaster 
exposing  the  knee  for 
extensive  dressings  but 
immobilizing  it  com- 
pletely. The  re-en- 
forced portions  of  the 
plaster  across  the  knee 
are  plaster  ropes  in- 
corporated in  the  leg 
and  in  the  thigh  plas- 
ter. 


Fig.  450.  —  Method 
of  immobilizing  the  hip 
and  allowing  it  ex- 
posed completely  when 
extensive  dressings  are 
necessary.  The  plaster 
ropes  are  placed  some 
distance  from  the  skin 
and  join  the  pelvis 
with  the  leg  portion 
of  the  plaster. 


Fig.  451. — A  method  of  applying 
plaster  and  maintaining  position  of 
the  foot  but  allowing  the  heel  and 
ankle  to  be  exposed  for  dressing. 
(See  figure  452.) 


335.  The  Application  of  a  Plaster  of  Paris  Bandage  after  Operation 
or  Manipulation  of  the  Knee. — To  facilitate  the  correction  of  knock 
knee  or  bow  leg  and  at  the  same  time  to  obtain  a  slight  hyperextension 
of  the  knee  during  the  application  of  plaster,  the  following  method  is 
of  service  in  very  muscular  individuals  or  when  much  force  is  necessary. 
The  leg  having  been  covered  with  sheet  wadding  from  the  toes  to 
the  groin,  a  heavy  felt  pad  is  placed  just  above  the  knee,  a  double 
four  inch  bandage  is  spread  over  this  pad  and  its  four  ends  carried 
down  to  a  leg  or  cross  bar  on  the  operating  table  and  tied  there  (see 
figure  76).  The  operator  can  then  slightly  hyperextend  the  knee  and 
correct  bowing  or  the  knock  knee  during  the  application  of  the  plaster. 

When  the  plaster  has  hardened  the  bandage  is  cut  away  from  its 
attachment.  In  cases  where  correction  of  the  knee  deformity  has  been 
done  the  plaster  should  extend  high  on  the  thigh.     It  should  grasp  both 


300 


TECHNIQUE  OF  OPERATIONS 


Fig.  452.— Plantar 

view  of  figure  451. 
The  lined  portion  is 
a  padded  wooden 
splint.  The  white  is 
a  plaster  and  extends 
beyond  the  heel. 
Dotted  line  marks 
the  heel. 

ends  of  each 
bone  and  fit  the 
thigh  well  and 
fit  the  leg  and 
foot  well.  Only 
in  this  way  can 
the  full  correc- 
tion be  main- 
tained. 

A  Simple 
Method  of  Pre- 
venting Rota- 
tion of  a  Leg 
Plaster.  —  Plas- 
ter ropes  are  ap- 
plied to  prevent 
the  rotation  of 
the  leg  as  shown 
in  figures  447 
and  448. 

336.  Plaster 
of  Paris  Band- 
age after  Oper- 
ation on  the 
Foot.  —  In  the 
application  of  a 
plaster  for  hold- 
ing the  foot,  it 
without  cramping 


Fig.  453.  — Front 
view  of  plaster  (fig- 
ures 451,  452).  The 
plaster  may  reach  to 
the  knee  or  above 
the  knee.  For  a  very 
complete  fixation  it 
should  reach  above, 
the  knee  being  flexed 
slightly  to  prevent 
rotation  of  the  plas- 
ter. 


Fig.  454.— Plaster  of  Paris  applied  with 
a  padded  wooden  sole  splint  and  "plaster 
ropes"  acting  as  a  cage  and  holding  the 
foot  at  right  angles.  This  is  useful  for  ex- 
tensive dressings. 


Fig.  455. — An  arrangement  for 
exposing  the  front  of  the  foot  for 
dressings  and  maintaining  posi- 
tion of  the  ankle  by  means  of 
plaster  of  Paris. 


Fig.  456.— Plantar 
view  for  either  fig- 
ure 454  or  455.  Dot- 
ted lines  show  the 
"plaster  ropes"  as 
they  extend  into  the 
plaster. 


is   important    to  hold  the  ball  of  the  foot  firmly 
the  toes.    A  small  strip  of  cotton  may  be  placed 


PLASTER  OF  PARIS  AND  BRACES 


301 


between  the  toes  and  folded  back  over  the  foot.  It  is  removed  after 
the  plaster  is  hard.  This  will  give  room  for  the  toes.  In  using 
pressure  on  the  ball  of  the  foot,  for  correction  during  the  application 
of  a  plaster,  the  surgeon  should  not  extend  the  toes  at  the  head  of 
the  metatarsal.  The  heel  should  be  padded  well;  pressing  the  plaster 
into  the  heel  should  be  avoided.  Pressure  over  the  dorsum  of  the  foot 
near  the  tibia  should  be  avoided,  either  directly  with  the  hand  or  forcing 
3  in  the  plaster  during  the  correction  of 

deformity.  When  correction  is  made 
the  plaster  is  apt  to  wrinkle  here  and 
cause  a  slough  unless  the  surgeon  is 
careful  to  get  his  correction  and  then 
apply  the  plaster.  If  the  plaster  is 
applied  first  and  the  correction  ob- 
tained afterward  the  wrinkling  of  the 
V 
"TT" 


Fig.  457. — Dr.  Bradford's  position  for 
manipulation  of  the  foot.  This  position 
is  used  during  the  application  of  the  plas- 
ter bandage  following  operation  on  the 
foot.  The  plaster  is  put  on  the  foot  from 
A  to  B;  only  two  turns  around  the  heel 

to  hold  this  "foot-cuff"  on.  The  knee  is  Fig.  458. — Position 
flexed  and  a  plaster  put  on  from  D  to  C.  of  the  foot  following 
When  these  portions  of  the  plaster  have  club  foot  operation.  Fig.  459.  —  Shoulder 
hardened  the  foot  is  held  in  position  and  The  foot  is  abducted,  plaster  with  plaster  ropes 
the  plaster  is  finished  uniting  the  foot  and  dorsally  flexed  and  used  when  extensive 
leg  portions.  the  cuboid  raised.         dressings  are  necessary. 

plaster  is  apt  to  result.  Methods  of  holding  deformities  during  the 
application  of  a  plaster  have  been  given  for  this  purpose  after  each 
operation.  In  applying  a  plaster  to  the  foot  after  correction  of  a  de- 
formity, when  the  knee  is  normal  the  plaster  is  applied  with  the  knee 
slightly  bent  to  prevent  the  rotation  of  the  plaster  on  the  leg.  When  the 
condition  or  an  operation  on  the  knee  will  not  allow  this  position,  a 
plaster  rope  included  in  the  plaster  can  be  used  to  prevent  rotation.  It 
extends  out  at  either  side  preventing  rotation  of  the  leg  in  bed  (see  figure 
447).  It  may  be  necessary  to  apply  the  plaster  around  the  pelvis  to 
prevent  the  plaster  from  twisting  if  the  knee  must  be  kept  straight. 
This  should  be  avoided  when  possible  as  it  complicates  the  care  of  the 
patient  in  bed.     See  figures  451  to  456. 


302 


TECHNIQUE  OF  OPERATIONS 


837.  Application  of  Plaster  for  Varus  or  Equino  Varus,  Club  Foot 
Plaster. — Some  care  is  necessary  in  applying  a  plaster  to  the  foot  for 
correction  of  bone  deformity.  A  liberal  quantity  of  well  fitting  sheet 
wadding  is  applied  to  the  foot  and  leg,  an  extra  amount  being  placed 
over  the  heel  and  between  the  toes.  About  eight  layers  of  plaster  band- 
age are  applied  around  the  ball  of  the  foot  and  metatarsals,  two  layers 
only  around  the  heel  to  prevent  this  cuff  from  slipping  off.  This  is 
allowed  to  harden  while  the  plaster  is  applied  to  the  thigh  and  leg  with 


Fig.  461. — Method  of  splitting  a  plaster  with  two  or 
more  jogs  so  that  the  two  halves  are  accurately  placed 
together.  This  jogging  of  the  plaster  may  be  done  for 
jackets  as  well  as  for  other  plasters. 


JL 


Fig.  460.  —  Shoulder 
plaster  used  when  exten- 
sive dressings  are  neces- 
sary. 

Fig.  462.  Plaster  knife.  These  plaster  knives  are  made 
the  knee  flexed  eighty  to  cut  leather;  they  may  be  obtained  by  the  dozen  at  less 
decrees    When  these  two  *^an  *en  cents  apiece.    It  is  easy  to  cut  with  the  point 

°  .  ,        i,i       without  endangering  the  patient. 

portions   are   hard,    the 

patient  is  turned  over  on  his  abdomen  and  a  pillow  is  placed  under 
the  knee.  The  operator  holds  the  foot  overcorrected  (see  figures  457  and 
458)  while  an  assistant  joins  the  two  portions  of  the  plaster.  In  this 
way  there  is  no  cramping  of  the  toes  which  are  held  flat  and  the  plaster 
is  applied  to  the  deformity  which  is  held  corrected.  If  the  operation 
has  been  thoroughly  done  the  foot  will  easily  overcorrect  without  force. 
Good  overcorrection  of  the  deformity  is  a  sure  method  of  preventing 
pressure  sores  and  discomfort  from  the  plaster.  The  position  of  over- 
correction of  the  foot  in  plaster  is  important.  A  vertical  line  through 
the  middle  of  the  lower  leg  is  drawn  on  the  plaster.  This  line 
should  be  determined  by  an  imaginary  plane  passed  through  the 
femur  and  tibia.  The  foot  should  be  abducted  fifty  degrees  from  this 
plane.  It  should  be  dorsally  flexed  about  twenty-five  degrees,  the 
cuboid  being  raised  more  than  the  rest  of  the  foot  (see  figures  457 
and  458). 


PLASTER  OF  PARIS  AND  BRACES 


30.- 


338.  Plaster  of  Paris  Bandage  for  Valgus.— A  plaster  of  Paris 
bandage  is  applied  from  the  toes  to  the  groin  with  the  knee  bent,  as 
follows:  a  liberal  quantity  of  well  fitting  sheet  wadding  is  applied  to  the 
foot  and  leg,  an  extra  amount  being  placed  on  the  heel  and  between  the 
toes.  Eight  turns  of  the  plaster  bandage  are  placed  over  the  ball  of  the 
foot  and  around  the  metatarsals  in  front.  Only  one  or  two  turns  are 
made  around  the  heel  to  hold  the  cuff  on.  The  cuff  is  allowed  to  harden 
while  the  plaster  is  put  on  from  above  the  ankle  to  the  groin  with  the 

knee  bent.  When  this  has 
hardened  the  patient  is 
turned  over  on  his  ab- 
domen, the  knee  rests  on  a 
cushion,  the  operator  holds 
the  ball  of  the  foot  in  a 
dorsal  position  and  adducts 
it,  correcting  the  deformity 
while  the  plaster  is  com- 
pleted between  the  foot 
cuff  and  the  leg.  The  heel 
should  not  be  allowed  to  be 
dented  or  to  rest  on  the 
table  or  bed.    After  an  ex- 


Fig.  463.— Poste- 
rior view  of  plaster 
shell  showing  the 
method  of  cutting 
out  a  lozenge-shaped 
piece  of  plaster  to 
allow  the  shell  to  be 
hyper  extended  at 
any  point  selected 
by  the  surgeon. 
Sometimes  it  is  bet- 
ter to  cut  out  trian- 
gular pieces  as  shown 
in  figure  464.  After 
bending  the  plaster 
it  is  re-enforced  by 
heavy  plaster  ropes 
as  shown  in  the  dot- 
ted lines. 


Fig.  464.  —  When 
the  plaster  of  Paris 
shell  is  made  on  the 
patient  it  must  be 
hyperextended  often 
at  the  point  selected 
by  the  surgeon. 
Triangular  pieces  are 
cut  out  at  either  side 
of  the  plaster  or  a 
lozenge  piece  is  cut 
out  of  the  middle  as 
shown  in  figure  463. 
This  allows  the 
bending  of  the  plas- 
ter. It  is  then  re- 
enforced  as  shown 
by  the  dotted  lines 
and  the  shell  com- 
pleted as  shown  in 
figure  465. 


Fig.  465. — Posterior  plaster  shell 
for  maintaining  position  of  the 
spine  in  recumbency.  This  shell 
will  not  rotate. 


J^> 


Fig.  466. — Cross  section  of  plas- 
ter shell,  showing  the  plaster  por- 
tion resting  on  the  table  preventing 
rotation. 


tensive  operation,  the  patient  is  kept  quiet  for  three  weeks.  After 
that  he  is  allowed  to  sit  in  a  chair.  At  the  end  of  the  fourth  week  he 
walks  on  the  other  foot  using  crutches.  Weight-bearing  is  allowed  in 
the  eighth  week  depending  on  the  case;  always  with  the  plaster  at 
first.  After  the  eighth  week  the  knee  may  be  flexed  twenty  degrees 
only. 

In  infantile  paralysis,  as  in  congenital  valgus,  overcorrection  is 
made  with  the  feet  in  marked  adduction  so  that  they  interfere 
in  walking.  This  is  maintained  for  at  least  six  months.  Walking 
is  made  possible  by  wooden  or  plaster  wedges  under  the  sole  of  the 
plaster. 


304 


TECHNIQUE  OF  OPERATIONS 


Fig.  467. — This  board  with  a  pelvic  rest  is 
fastened  to  any  table  and  is  used  to  support 
the  sacrum  during  the  application  of  a  pelvic 
plaster. 


Fig.  46S. — A  box  used  to  support  the 
thorax  of  a  patient  during  the  application 
of  a  pelvic  plaster. 


Fig.  469.  —  Portable  Goldwait 
frame  for  the  application  of  plaster 
jackets. 

339.  Plaster  of  Paris  after 
Operation    on    the    Toes. — 

There  is  some  difficulty  in 
maintaining  the  overcorrec- 
tion of  hammer  toe  in  a 
comfortable  manner  without 
interfering  with  the  circula- 
tion. 

In  the  first  place,  as  in  the 
case  of  any  deformity,  the 
overcorrection  after  operation 
should  be  so  complete  that 
the  toe  may  be  put  in  any 


Fig.  470.  —  Posterior 
view  of  modified  Taylor 
back  brace.  The  U  piece 
should  be  broad  and  ex- 
tends down  almost  to 
the  tuberosity  of  the 
ischium  at  the  side.  Its 
top  should  be  broader 
than  the  posterior  supe- 
rior spines;  the  uprights 
rest  on  the  transverse 
processes,  the  cross  bars 
help  to  immobilize. 


Fig.  471.  —  Shows 
the  front  view  of  the 
two  leather  or  canvas 
aprons  used  to  hold 
the  Taylor  brace  in 
place. 


position  without  force  or  ten 

sion.    A  well  fitting  plaster  is  then  applied  to  the  ankle  and  ball  of  the 

foot,  often  the  leg  is  included. 

Incorporated  in  the  dorsal  part  of  the  plaster  are  five  digit-like  pro- 


PLASTER  OF  PARIS  AND  BRACES 


305 


Fig.  472.  —  Side 
view  of  the  straps 
and  the  Taylor  back 
brace. 


Fig.  473.  —  Brad- 
ford abduction  splint 
and  high  sole.  Back 
view. 


jections  made  of  plaster  bandages  moulded  to 
protrude  beyond  the  toes  (see  figures  190  to 
194).  When  they  have  hardened  a  pad  is  placed 
under  each  projection,  holding  its  metatarso- 
phalangeal joint  flexed;  a  felt  pad  is  then  placed 
under  the  ball  of  each  toe  and  a  gauze  bandage 
is  looped  around  the  toe  and  felt  pad  draw- 
ing it  up  to  its  plaster  digit,  holding  the  phalangeal 
joint  hyperextended  (see  figure  190). 

A  similar  plaster  may  be  used  for  the  hand  when  a  wire  or  aluminum 
is  not  available.    The  splint  is  preferable  for  the  fingers. 

This  method  of  applying  plaster  is  perfectly  comfortable  if  the  opera- 
tion is  done  completely  so  that  no  force  is  necessary  to  hold  the  over- 
correction. 


Fig.  474.— Bradford 
abduction  splint  and 
high  sole,  front  view. 
This  splint  is  practi- 
cally a  Thomas  knee 
splint  with  one-half  of 
a  Thomas  ring  on  the 
opposite  side,  the  two 
connected  by  a  pubic 
iron  in  the  shape  of  a 
horse  shoe.  This  pubic 
portion  is  from  two  to 
three  inches  broad. 
The  measurement  of 
the  Thomas  knee 
splint  is  otherwise  the 
same. 


CHAPTER  III 

PREPARATION  FOR  OPERATION 


Fig.  475. — Long  caliper  splint  used  to  im- 
mobilize the  knee  and  ankle  with  two  leather 
anterior  bands,  one  to  hold  the  upper  end  of 
the  tibia,  the  other  the  lower  end  of  the  femur. 
One  or  both  of  these  may  be  used,  depending 
on  the  use  of  the  brace.  If  an  operation  has 
been  done  above  the  patella,  it  is  better  to 
use  the  lower  band  only.  If  an  operation 
has  been  done  below  the  patella  it  is  better  to 
use  the  upper  one  only.  Where  the  splint  is 
used  and  no  operation  has  been  done  in  front 
of  the  knee,  an  ordinary  knee  band,  as  shown 
in  figure  476  may  be  used  instead  of  these  two 
anterior  bands.  This  splint  fits  into  a  socket 
attached  to  a  shoe.  It  reaches  from  one  and 
one-half  inches  below  the  fold  of  the  buttock 
to  the  sole  of  the  foot.  The  uprights  follow 
the  outline  of  the  leg.  A  tracing  is  taken  of 
the  leg  for  this  purpose.  This  splint  may  be 
made  with  a  joint  at  the  knee  which  locks 
or  allows  varying  degrees  of  motion.  (See 
figure  478). 


Fig.  476. — This  is  a  knee  cap  which  fits 
over  the  patella  and  is  used  to  keep  the 
knee  straight  when  used  with  a  long  cali- 
per splint.     (See  figure  495.) 


ra 


Fig.  477. — Short  caliper  splint  used  to 
immobilize  the  ankle.  This  splint  fits  into 
a  socket  attached  to  a  shoe.  This  splint 
reaches  from  the  tuberosity  of  the  tibia  to 
the  sole  of  the  foot.     (See  figure  478). 


Fig.  478. — The  caliper  splint  (see  fig- 
ures 475  and  477)  may  be  arranged  at  its 
lower  end  with  a  caliper  stirrup  as  shown 
above.  This  allows  the  splint  to  be  fas- 
tened to  the  shoe  by  means  of  straps  in- 
stead of  having  a  socket  made  in  the  shoe 
for  the  purpose  of  holding  the  splint.  One 
strap  goes  over  the  midtarsus,  the  other 
over  the  heel  of  the  shoe. 


340.  Preparation  for  Operation. 

— In  the  preparation  of  the  patient 
for  operation  the  skin  must  be  clean 
and  free  from  irritation.  If  iodine 
is  to  be  used,  the  surface  should  not  be  bandaged  tightly  beforehand. 
Soap  and  water  should  not  be  used  for  at  least  twenty-four  hours  before 
iodine.  For  shaving  previous  to  the  use  of  iodine,  a  paste  of  water  and 
talcum  powder  or  plain  water  is  used,  the  application  of  3  3^%  tincture  of 

306 


PREPARATION  FOR  OPERATION 


307 


iodine  will  be  sufficient  for  the  preparation  of  a  fairly  clean  skin. 
Where  it  is  necessary  to  use  soap  and  water  it  is  not  advisable  on  the 
chronic  debilitated  patient  to  follow  this  with  tincture  of  iodine.    When 


Fig.  479.  — Method  of 
re-enforcing  the  boot  to 
immobilize  the  ankle.  A 
piece  of  sole  leather 
(dotted  portion)  is 
stitched  inside  of  the  shoe, 
on  both  sides  of  the  ankle. 
A  hole  is  cut  in  the  sole 
leather  where  the  mal- 
leolus rests. 


Fig.  482. 


Fig.  4  8  0.  —  Posterior 
view  of  a  short  caliper 
splint  applied  to  hold  the 
ankle  in  an  over  corrected 
position.  Notice  the 
wedge  under  the  shoe  and 
the  extension  of  the  wedge 

laterally.     The  caliper  is  jrIG.  483.— Method  of  holding  the  leg  when  the 

bent  to  maintain  the  over  skjn  0f  the  f00t  and  ankle  are  being  prepared  for 

corrected  position  desired.  operation. 

it  is  necessary  to  use  soap  and  water  the  part  is  thoroughly  scrubbed 

with  water  and  green  soap  on  a  gauze  sponge.    The  skin  is  first  shaved, 

cleaned  with  soap  and  water,  the  soap  is  then  entirely  washed  off  with 

fresh  water  and  the  skin  thoroughly  scrubbed  with  a  70%  solution  of 

alcohol  or  with  Harrington's  *  or  some  other  solution  on  a  gauze  sponge. 

*  (Harrington  solution) 

Bichloride  of  Mercury 1  5-10  grams 

Hydrochloric  Acid 100  cc 

Glycerine 100  cc 

Alcohol 1200  cc 

Distilled  water 2000  cc 


308 


TECHNIQUE  OF  OPERATIONS 


Fig.  485. 


■A  sterile  towel  is  put  on  the  sterilized 
skin  above. 


The  alcohol  should  be  used  very  freely  from  a  basin  sterilized  by  boiling 

and  the  scrubbing  systematically  done. 

When  there  is  to  be  much  manipulation  at  the  time  of  operation,  the 

iodine  preparation  should  not  be  used,  any  friction  over  iodine  will  cause 

blistering  of  the  skin. 

In  "cleaning  up"  a  patient  and  in  placing  the  protective  towels  and 

sheets,  etc.,  the  assistants  should  be  trained  to  be  systematic  and  rapid; 

one  space  should  be  taken  up 
after  another  and  done  thor- 
oughly. There  should  be  no 
waste  of  time  or  delays,  a 
nurse  should  be  ready  with 
each  covering  for  the  patient, 

Fig.  4S4.— The  skin  is  sterilized  from  M  to  N.         handing   it    promptly  to  the 

assistant  in  the  order  it  is 
expected. 

In  "cleaning  up"  a  leg  or 
an  arm  the  following  method 
may  be  used : 

341.  Preparation  of  the 
Leg  and  Foot  for  Opera- 
tion.— The    hair    is    shaved 

the  day  before,  using  no  soap  if  an  iodine  preparation  is  to  be  used. 
When  iodine  is  not  used  the  upper  end  of  the  leg  is  cleaned  by  the 
nurse,  starting  at  the  front  of  the  upper  end  of  the  thigh  (see  figure  481), 
a  section  of  the  leg  is  scrubbed  from  (a-b)  to  (c-d)  on  the  outer  side  and 
then  back  from  (c-d)  to  (a-b).  Another  section  is  next  cleaned  on  the 
inner  side  from  (a-b)  to  (c-d)  and  then  back  from  (c-d)  to  (a-b).  This 
process  is  repeated  twice.  The  nurse  next  cleans  in  a  similar  way  the 
next  section  of  the  leg  which  overlaps  the  first  section  and  extends  from 
a-prime,  b-prime,  c-prime,  d-prime.  In  the  same  way  the  third  section  is 
made  to  overlap  the  second  and  a  fourth  section  overlaps  the  third  and 
so  on  down  the  leg  (see  figure  482) .  In  this  way  the  leg  is  cleaned  com- 
pletely first  with  soap  and  water  and  second  with  the  antiseptic  solution 
desired.  Additional  cleansing  may  be  used  at  the  regions  where  the 
incisions  are  to  be  made.  When  the  foot  is  to  be  prepared  a  nurse  holds 
the  leg  just  below  the  knee  as  seen  in  figure  483. 

When  the  foot  is  thoroughly  cleaned  it  is  held  by  a  sterile  nurse 
with  a  sterile  towel.  The  leg  is  then  cleaned  up  from  below  up- 
ward, using  one  section  after  another  as  demonstrated  in  figure  482. 
When  the  leg  is  thoroughly  cleansed  it  is  still  held  by  a  clean  assist- 
ant while  a  sterile  sheet  is  applied  over  the  operating  table,  under  the 
leg,  second,  a  sterile  towel  is  wound  around  the  cleaned  skin,  high  up 
on  the  leg  to  mark  the  sterile  limit  (figure  485).  This  towel  overlaps  the 
sterilized  skin  and  is  clamped  or  tied  so  that  it  will  not  expose  the  non- 
sterile  skin.    A  sheet  is  placed  over  the  patient  and  the  upper  leg,  covering 


PREPARATION  FOR  OPERATION 


309 


it  below  the  towel  which  has  just  been  mentioned  and  clamped  around  it. 
The  patient  is  then  ready  for  operation.  One  or  more  sand  bags  are  use- 
ful in  an  operation  on  the  leg,  arm  and  foot.  A  sterile  sheet  doubled  is 
placed  on  a  sterilized  table,  a  sand  bag  placed  on  it,  the  sheet  is  folded 
over  it  several  times 
and  the  edges  turned 
in.  The  sand  bag  may- 
then  be  handled  by 
the  operator  and  his 
assistants. 

When  a  middle  por- 
tion of  the  leg  is  to  be 
operated  upon,  as  for 
instance  the  knee,  the 
leg  may  be  prepared  in 
the  manner  described 

above  from  the  points  Fig.  486.— A  sterile  sheet  is  put  on  the  operating  table, 
fm-n)  (figure  484)  a  another  over  it.  The  foot  is  placed  on  the  second  sheet. 
V  -         -i  •/      .     (See  figure  487.) 

non-s  t  e  r  i  1  e  assistant 

holding  the  foot  so 
that  the  leg  is  off  of 
the  side  of  the  oper- 
ating table  and  easily 
cleaned  on  all  sides. 

When  the  leg  is 
surgically  clean,  a 
doubled  sterile  sheet 
is  placed  on  the  oper- 
ating table  while  the 
leg  is  held  up,  second, 

Fig.  487.— The  sterile  sheet  covers  the  lower  part  of  the  tn®  stpnle  towel  IS 
sterilized  skin  (figure  484)  and  the  foot  around  which  it  is  rolled  JUSt  below  the 
folded  and  tied.     (See  figure  488.)  point    cleaned    Up 

above  the  knee  (m)  and  another  just  above  the  point  cleaned  up 
below  the  knee  (n);  third  (see  figure  490)  a  doubled  sheet  is  laid 
over  the  patient,  and  the  leg  and  upper  leg  towel.  A  sheet  is 
placed  on  the  operating  table  (see  figure  486).  The  nurse  lays  the 
foot  and  presses  it  in  place  on  this  sterile  sheet  and  wraps  it  around 
the  leg  as  in  figures  487,  490.  The  loose  end  beyond  the  toes  is  folded 
back  over  the  foot.  This  is  tied  with  a  strip  over  the  foot,  around 
the  ankle  and  around  the  leg.  Instead  of  using  strips,  a  towel  folded 
five  or  six  inches  broad  and  rolled  may  be  bandaged  around  the  foot  and 
ankle  to  hold  the  sheet  in  place.  This  will  give  firmness  and  keep  the 
sheet  from  slipping  during  manipulation  of  the  leg  (see  figures  491  and 
492).  The  advantage  of  using  a  sheet  to  envelop  the  lower  leg  and 
foot  is,  first,  the  saving  of  time  as  it  is  not  necessary  to  prepare  this  great 


310 


TECHNIQUE  OF  OPERATIONS 


extent  of  skin  and  second,  the  operator  is  able  to  manipulate  the  leg 
which  is  protected  in  a  sterile  sheet. 

342.  Preparation  of  the  Knee  Flexed  at  Right  Angles  for  Operation 
on  the  Semilunar  Cartilage,  etc. — The  knee  is  prepared  and  protected 
as  described  above.  Sterile  sheets  include  the  leg  above  and  below  the 
knee  and  the  foot.  The  end  of  the  operating  table  is  let  down  and  the 
patient's  leg  allowed  to  flex  at  right  angles  off  of  the  end  of  the  table. 
Sterile  sheets  protect  the  leg  from  the  tableleaf  and  hang  from  the  operat- 
ing table  almost  to  the  floor.  The  surgeon  may  stand  or  may  sit  in 
front  of  the  knee  and  rests  the  foot  on  a  sterile  sheet  placed  in  his  lap 

over  his  gown.  Assist- 
ants stand  on  either 
side  of  the  knee. 

343.  Preparation  of 
the  Arm  for  Opera- 
tion.— When  the  elbow 
or  arm  near  it  is  to  be 
operated  on,  the  prepa- 

Fig.  4SS.— The  foot  and  leg  are  now  well  covered  with  ration  is  similar  to  that 
sterile  sheets  which  cannot  slip  in  manipulation  of  the  described  for  the  mid- 
leg.  (See  figure  489.)  die  of  the  leg.  For  the 
forearm  or  hand  the 
preparation  is  used  as 
described  for  the  leg 
and  foot. 

344.  Preparation  of 
the  Shoulder  for  Op- 
eration (see  figure 
493). — In  operation  on 
the  shoulder  the  prep- 
aration     should       be 

made  from  the  middle  Fig.  489.— A  double  sheet  is  now  placed  over  the  upper 
line  On  the  thorax  an-  sterile  towel  and  clamped.     (See  figure  490.) 

terior  to  the  middle  line  posterior,  and  as  far  down  as  the  waist.  The 
arm  is  prepared  to  the  elbow.  In  the  preparation  of  the  shoulder 
and  outer  scapula  region  the  patient  lies  on  his  back  with  hard 
pillows  or  sand  bags  or  sawdust  bags  holding  the  pelvis  rotated  forward 
forty-five  degrees.  A  large  sand  bag  beneath  the  shoulder  blades 
holds  the  posterior  deltoid  region  six  inches  off  of  the  operating 
table. 

As  soon  as  the  patient  is  anaesthetized  he  is  placed  on  these  cushions. 
If  the  right  side  is  to  be  operated  upon  he  is  then  rolled  well  over  on  the 
left  side  to  give  access  to  the  back.  The  scapula  and  trapezius  region 
are  cleaned  with  sterilizing  solution  to  the  median  line,  also  the  shoulder 
and  arm  to  below  the  elbow.  The  front  of  the  chest  is  sterilized  to  the 
median  line  and  to  below  the  nipple,  lower  if  necessary.    A  double  sterile 


PREPARATION  FOR  OPERATION 


311 


Fig.  490. 


Fig.  491. — The  knee  is  now  ready  for  operation.     (See 
figure  492). 


Fig.  492.— The  sheet  on  the  foot  and  lower  leg  may  be 
fastened  with  towels  as  shown  in  figure. 


Fig.  493.— In  operations  on  the  shoulder  a  sand  or  sawdust 
pillow  is  placed  to  the  inner  side  of  the  scapula.    The  shoulder 

!lnef  *i!f  Slde  °f  the  °Perating  table.  This  position  makes 
the  shoulder  accessible  in  front  and  behind  without  changing 
the  position  of  the  patient  during  the  operation. 


Fig.  494.  —  The  osteo- 
tome on  the  market;  side 
view  of  its  blade,  as  it 
should  not  be;  there  should 
be  no  sudden  shoulder  near 
its  cutting  edge.  The  sur- 
geon should  be  able  to  feel 
with  the  end  of  the  osteo- 
tome; any  sudden  curve  or 
shoulder  is  a  disadvantage. 
(See  figure  496.) 


U 


Fig.  495.— The  fiat 
side.  An  osteotome 
should  have  a  large  handle 
so  that  it  may  easily  be 
controlled.  Its  sides 
should  not  flare  too  much. 


312  TECHNIQUE  OF  OPERATIONS 

sheet  is  placed  under  the  scapula  and  thorax  over  the  sand  bags,  the 
patient  is  then  allowed  to  roll  back  into  the  position  at  first  described. 
The  hand  which  is  not  sterilized  is  still  being  held  by  a  non-sterile  nurse. 
A  sterile  sheet  doubled  covers  the  head  and  neck.  It  is  caught  above 
the  shoulder  by  clamps  to  the  sheet  on  the  table.  Another  sheet  doubled 
reaches  from  the  neck  across  the  chest  above  the  nipple  continuing  off 
of  the  operating  table.  This  sheet  is  clamped  to  the  second  sheet  at  the 
neck  and  to  the  first  sheet  at  the  side  of  the  operating  table.  A  fourth 
sheet  doubled  is  placed  over  the  rest  of  the  abdomen  and  legs,  covering 
the  patient  and  the  operating  table  completely.  The  non-sterile  hand 
and  forearm  is  still  held  by  an  assistant.  A  doubled  sterile  sheet  is 
placed  over  the  thorax  just  below  the  shoulder.  The  non-sterile  assistant 
places  the  hand,  forearm  and  elbow  firmly  on  this  sheet  and  steadies  it  by 
the  non-sterile  part  until  a  clean  assistant  grasps  the  sterile  arm  above  the 
elbow  and  steadies  it  while  the  sheet  isfolded  from  without  inward  over  the 
arm  and  hand.  The  inner  part  of  the  sheet  is  then  folded  over.  The  end 
of  the  folded  sheet  beyond  the  fingers  is  turned  back  over  the  hand.  Two 
towels  folded  five  or  six  inches  broad  and  rolled  are  now  used.  One  is 
bandaged  about  the  wrist  holding  the  turned  over  end  of  the  sheet,  the 
other  is  bandaged  about  the  elbow  holding  the  sterile  sheet  well  above 
the  elbow.  These  towels  are  pinned  or  clamped.  Gauze  strips  may 
be  used  instead  of  the  towels.  The  folded  flat  towel  holds  the  sheet 
firmly  and  has  body  enough  to  prevent  slipping. 

345.  Preparation  of  the  Elbow  for  Operation. — In  the  preparation 
of  the  elbow  for  operation,  the  patient  lies  on  his  back,  a  non-sterile 
nurse  holds  the  hand  of  the  arm  to  be  operated  upon. 

The  arm  is  cleaned  from  the  wrist  to  the  axilla  in  a  manner  described 
for  cleaning  the  leg.  A  sterile  towel  already  folded,  four  to  six  inches 
broad  and  rolled  is  applied  around  the  upper  arm. 

If  it  is  necessary  to  operate  high  on  the  upper  arm,  the  shoulder  and 
axilla  are  prepared  and  a  small  sheet  or  double  towel  is  looped  around 
the  shoulder  as  shown  in  figure  493.  A  sterile  assistant  now  holds  the 
arm  just  below  the  elbow.  The  operating  table  is  now  covered  with  ster- 
ile sheets,  a  large  towel  doubled  is  placed  on  the  operating  table.  The 
assistant  places  the  hand  and  lower  third  of  the  forearm  on  it.  The 
towel  should  be  large  enough  to  fold  around  the  hand  at  least  three  times. 
When  folded  the  end  extending  beyond  the  fingers  is  doubled  over  the 
hand.  One  of  two  methods  may  be  used,  either  a  strip  is  placed  around 
the  hand  and  tied  and  another  around  the  wrist  and  tied,  holding  the 
towel  in  place,  or  a  towel  previously  folded  four  to  six  inches  broad  and 
rolled  is  bandaged  to  hold  on  the  towel,  covering  the  wrist  and  hand. 
The  towel  is  clamped  or  pinned  in  place.  The  arm  is  now  placed  across 
the  thorax  or  on  the  operating  table  or  on  a  small  table  or  on  a  shelf 
covered  with  a  doubled  sterile  sheet. 

346.  Preparation  of  the  Hand  and  Forearm  for  Operation. — If 
the  hand   is  to  be  operated  on,  a  non-sterile  nurse  holds  the  arm 


PREPARATION  FOR  OPERATION 


313 


firmly  with  both  her  hands  just  below  the  elbow,  the  patient's  fingers 
and  hand  and  arm  are  cleaned  up  to  the  forearm  without  disturbing  the 
holder  of  the  arm.  A  sterile  towel  previously  folded,  four  to  six  inches 
broad  and  rolled,  is  bandaged  firmly  above  the  wrist  and  clamped.    The 


Fig.  496. — Side  view 
of  an  osteotome  show- 
ing the  gradual  slant 
without  any  bulge  near 
the  cutting  edge. 


Pig.  49  9. —The 
straps  are  next  crossed 
under  the  foot. 


Fig.  497.— Dr.  Hay- 
ward  Cushing's  knot 
for  temporary  traction 
during  an  operation. 
The  tendo  achilles  and 
foot  are  padded  with 
heavy  pads  such  as 
saddle  felt;  then  a 
heavy  webbing  strap 
is  applied  first  to  the 
back  of  the  leg. 


Fig.  500.  —After 
crossing  under  the  foot 
they  are  brought  up 
on  the  sides  of  the  foot 
and  looped  through  the 
first  part  of  the  web- 
bing. 


Fig.  498.— The  strap 
is  crossed  over  the  tar- 
sus which  is  well  pad- 
ded. 


Fig.  501.  —  When 
the  straps  are  pulled 
tight  a  side  view  shows 
the  pull  near  the  mal- 
leoli preventing  con- 
striction of  the  ankle 
during  the  application 
of  force. 


hand  is  placed  on  a  sterile  table,  a  sheet  doubled  covers  the  arm  from 
the  wrist  over  the  sterile  towel. 

For  operations  on  the  forearm,  the  preparation  is  similar. 

347.  Preparation  of  the  Hip  for  Operation. — In  the  preparation 
for  the  right  hip,  the  patient  is  placed  on  his  left  side  close  to  the 
left  edge  of  the  operating  table;  the  foot  is  held  by  a  non-sterile  as- 
sistant, the  leg  is  prepared  on  all  sides  from  below  the  knee  to  the 
perineum  as  described  above.  The  assistant  holds  the  foot  high  enough 
to  afford  easy  access  to  all  parts  of  the  leg.     The  body  is  prepared  from 


314 


TECHNIQUE  OF  OPERATIONS 


the  waist  down  to  the  leg,  extending  beyond  the  median  line  in  front  and 
behind.  Four  sterile  sheets  are  now  used  on  the  patient,  a  fifth  on  the 
leg.  When  the  patient  is  clean  a  doubled  sterile  sheet  is  placed  on  the 
operating  table  behind  the  patient;  the  patient  is  turned  back  over  it. 
The  leg  is  still  held  up  off  of  the  operating  table  by  the  non-sterile  assist- 
ant.    A  sheet  is  placed  under  it  over  the  non-sterile  leg  and  operating 


Fig.  502.  —  Plantar 
view  showing  crossing 
of  straps. 

table.  A  sterile 
sheet  doubled  is 
placed  under  the 
clean  leg,  close  to 
the  perineum  and 
up  over  the  ab- 
domen, another 
covers  the  patient 
and  table  above 
the    anterior 


Fig.  503. — The  straps  are  tied  together 
under  the  foot  making  a  hook  to  which 
traction  may  be  applied.  When  much 
traction  is  necessary  the  usual  ordinary 
webbing  may  be  used  if  three  thicknesses 
are  used  folded  together  and  used  to- 
gether. 


Fig.  504.— Method 
of  padding  before 
applying  the  straps 
for  traction  (see  fig- 
ure 503) .  Heavy 
saddle  felt  (z/i  of  aa 
inch  thick)  is  used 
cut  four  inches  broad 
and  thirty  inches 
long.  It  is  folded 
over  the  tendo 
achilles  and  front  of 
the  foot;  the  padding 
may  advantageously 
include  the  sole  of 
the  foot. 


spines.  These  are 
all  clamped  where  they  cross  each  other.  The  whole  table  and  other  leg 
are  now  covered  with  the  fourth  sterile  sheet.  A  fifth  doubled  sheet  is 
placed  on  the  operating  table  to  receive  the  foot  of  the  cleaned  leg  which  is 
placed  firmly  on  it  by  the  non-sterile  assistant  and  held  until  it  is  steadied 
by  the  clean  assistant,  grasping  the  thigh  while  the  outer  edge  of  the 
sterile  sheet  is  folded  inward  over  the  leg  and  foot.  The  inner  part  of  the 
sheet  is  then  folded  around  the  leg.  At  the  foot,  the  sheet  beyond  the 
toes  is  folded  back  over  the  foot;  a  towel  previously  folded  four  to  six 
inches  broad  and  rolled  is  bandaged  and  clamped  around  the  foot  and 
ankle  to  hold  the  sheet  in  place.  Another  towel  like  this  is  applied 
above  the  knee  to  hold  the  upper  end  of  the  sheet  in  place.  This  pre- 
vents any  possibility  of  disturbing  the  protection  during  manipulation  of 
the  leg. 


INDEX 

The  author  will  be  glad  to  know  of  any  methods  or  practical  points  that  have  been 
of  value  to  surgeons  in  operations  on  bones,  joints,  muscles  and  tendons. 
Any  suggestions  will  be  welcomed. 

All  numbers  refer  to  paragraphs  unless  figures  are  mentioned 

A 

Abducted  hip,  see  hip  deformity 
Achilles  tendon,  lengthening,  127 
"  "       shortening,  146 

"  "       tenotomy,  132 

Acromion  depressed,  205,  224 

"         in  obstetrical  paralysis,  208,  211 
"         osteotomy  for,  205,"  224 
"         shoulder  dislocation  with,  205-211,  224 
Acute  arthritis  of  infancy,  46 
Adducted  hip,  see  hip  deformity 
Adductor  incision  at  the  hip,  24,  31 
"       magnus  tenotomy,  31 
"       myotomy,  69 
Adjusting  the  length  of  the  legs,  42 
After-treatment,  see  under  each  operation 
Albee  bone  grafting,  the  spine,  321 

"    hip  operation  for  osteo-arthritis,  40 
"    operation  for  ankylosing  of  the  spine,  320 
Ankle,  ankylosis  of;  arthroplasty,  192,  193 
"      ankylosis;  astragalectomy,  168,  192 
".      arthrodesis,  179 
"      arthrotomy,  180 

anterior  external  incision,  181 
"  "  anterior  internal  incision,  183 

"  anterior  median  incision,  185 

"  circular  incision,  186 

"  Kocher  incision,  186 

"  metatarsal  incision,  196 

"  posterior  external  incision,  182 

"  posterior  internal  incision,  184 

"      arthroplasty,  192-193 
"      astragalectomy,  168 
"      Bradford  silk  ligament,  173 
"      bone  operation  for  cavus,  116 

for  club  foot,  105 
"  "  "         for  valgus,  110-111 

"  "  "         for  varus,  104,  105,  106 

"      calcaneus,  115 
"      calliper  splint,  fig.  477 
"      circular  incision,  186 
"      claw  foot,  118-124 
"      club  foot,  104-108 

315 


316  INDEX 

Ankle,  contracted  tendons,  118-124 
toes,  11S-124 
"      dangle  foot,  1GS,  179 

"      deformities,  see  varus,  valgus,  cavus,  equmus,  see  Part  III,  Chapters  I— III 
"  "  equinus,  117,  129 

"  •    "  equino  valgus,  109-114 

"      ,   equino  varus,  104-108 
"      excision,  168,  195,  197 
"      flail,  179 
"      flat  foot,  109-114 
"      fracture,  117,  187-190 
"      hammer  toe,  claw  foot,  118-124 
"      hallux  valgus  and  foot  deformity,  125 
"      incision,  see  Incisions,  1S1-186,  Part.  Ill,  Chapter  IV 
"      infantile  paralysis,  see  deformities,  paralysis,  transplantation 
"      joint,  tibio-tarsal,  complete  exposure  for,  186 
"      manipulation  with  Bradford  wrench,  102 
"  "  "    club  foot  wrench,  101-103 

"  "  "    Davis  wrench,  103 

"  "  "   flat  foot  wrench,  101,  103 

"  "  "   Thomas  wrench,  101 

"      muscle  transplantations  in,  see  paralysis,  muscle  transplantation 
"      Ober  operation  for  club  foot,  106 
"      osteomyelitis,  198,  323 
"      paralytic  conditions  of,  151-164,  166 

"      plaster  of  Paris  for,  Figs.  451-456,  see  under  each  operation 
"      poliomyelitis,  see  deformities,  paralysis 
"      posterior  external  incision,  182 
"  "        internal  incision,  183 

"      Potts  fracture  deformity,  117 
"      preparation  of  the  skin  for  operation,  341 
"      puncture  of  the  ankle  joint,  191 
"      silk  ligaments,  subcutaneous  method,  173 
"         "  "  by  open  method,  172 

"      supports,  figs.  477,  479,  4S0 
"      suppurative  conditions,  194-201,  323 
"      tapping  of,  191 
"      tendon  fixation,  174 

"      lengthening,  138,  139,  140 
"  "      shortening,  144-148 

"  "      transplantation,  see  muscle  transplantation,  paralysis 

"      tuberculosis,  197 
"      valgus,  109-113 
"      varus,  104-109 
"     weak,  171,  172,  173,  Chapter  III 
"      wrenches,  Bradford,  102 

club  foot,  101-103 
Davis,  103 
flat  foot,  101,  103 
Thomas,  101 
Ankylosis  of  the  ankle,  Section  III,  Chapter  V 
"     "       "      arthroplasty,  192 

"        "     "       "      equinus  position,  operation  for,  117,  129 

"        "     "  elbow,  Part  V,  Chapter  V 

"        "     "       "       arthroplasty,  271-272 

"        "     "       "       excision,  269 


INDEX  317 

Ankylosis  of  the  finger,  arthroplasty,  308 
"        "     "  hip,  34 
"        "     "      "    arthroplasty,  35 
"        "     "      "    Gant  operation  in  cases  of,  37 
"        "     "      "    excision  for,  44 
"        "     "      "    osteotomy,  in  cases  of,  39 
"        "     "  jaw,  arthroplasty,  318 
"        "     "  knee,  Chapter  V,  also  94 
"     "       "     arthroplasty,  95 
"     "  shoulder,  Part  IV,  Chapter  V 
"        "     "  "         arthroplasty  for,  241 

"        "     "  "         excision  for,  239-240 

"        "     "  spine,  by  Albee  operation,  321 
"        "     "       "      by  bone  graft,  320 
"        "     "       "      by  Hibbs  operation,  316,  322 
"        "     "       "      by  plastic  operation  on  the,  320 
"        "     "  wrist,  Part  VI,  Chapter  IV 
"        "     "       "      arthroplasty,  307 
"        "     "       "      excision  for,  311 
Apparatus  after  operation,  see  under  each  operation 

"  "  "  see  also  plaster  of  Paris 

Apparatus  for  ankle,  caliper  splint,  Fig.  477 
"  back,  brace,  Figs.  470-472 
"  Bradford  frame,  Figs.  8,  9,  10,  24 
"  "  caliper  splint,  long  and  short,  Figs.  475-478 

"  Carrell  technique,  323M 
"  "  Carrell-Dakin  technique,  323 

"  "  congenital  hip  machine,  Figs.  1-3 

"  "  extension  or  flexion  of  the  fingers,  Fig.  402 

"  "  finger,  Figs.  442,  446 

"  "        "      after  operation  on  the,  333 

"  "  fracture  of  the  femur  in  infants,  Figs.  67-70 

"  "  hallux  valgus,  Figs.  198-200 

"  "  hand,  after  operation  on  the,  333 

"  "hip  splint,  Figs.  473-474 

"  "     "    traction  apparatus  for  use  during  the  operation,  Figs.  54-61 

"  "  knee  caliper  splint,  Fig.  475 

"  "  manipulating  the  foot,  100 

"  "  preventing  inward  rotation  of  the  forearm,  Fig.  395 

"  shoulder  shelf,  Figs.  314,  315 
"  "  toes,  Figs.  190-194 

"  "  traction  during  operation  on  the  leg  or  arm,  235,  Figs.  55,  61 

"  "         "        on  the  arm,  262 

"  "         "        on  the  elbow,  262 

"  "         "        on  the  leg,  Figs.  54,  57 

on  the  shoulder,  235 
"  "  wrist,  after  operation  on  the,  323 

Arm,  see  shoulder,  elbow,  wrist,  hand 
"     operation,  overhead  sling  after,  273 
"     preparation  of  the  skin  for  operation,  343 
"     traction  apparatus  for  fractures,  235 
Arthritis  of  infancy,  acute,  46 

Arthrodesis  of  the  ankle,  179,  see  astragalectomy,  silk  ligaments 
"   "    elbow,  255 
"   "  "      silk  ligaments,  252 

"    "    flail  ankle,  179 


318  INDEX 

Arthrodesis  of  the  hip,  12-40 

silk  ligaments,  13 
"   "    knee,  75 

"    "       "      silk  ligaments,  77 
"    "     osteo-arthritis  of  the  hip,  12 
"    "     paralytic  conditions,  see  under  each  joint 
"   "    shoulder,  225 

"    "     silk  ligament  for,  see  silk  ligaments 
"  "    "     tibio-tarsal,  179 

"  ankle,  192 

astragalo-scaphoid,  114 
"  elbow,  271-272 

"  finger,  308 

"  hand,  306-308 

"  hip,  34,  35 

"     Murphy,  34,  35 
"  knee,  95 

Murphy  principles,  see  under  each  joint 
phalangeal,  308 
"  shoulder,  241 

"  wrist,  306-308 

tempomaxillary,  318 
"  tibio-tarsal,  179 

Arthrotomy,  Ankle,  181-186 

"     anterior  median  incision,  185 
"     circular  incision,  186 
"     external  anterior  incision,  181 
"        posterior  incision,  182 
"     internal  anterior  incision,  183 
posterior  incision,  184 
"     Kocher  incision,  186 
"     tarsal  incision,  181-186 
"     and  foot,  Part  III,  Chapter  IV 
Carpal,  298-301 

"       anterior  incision,  300 
"       external  incision,  301 
"       Oilier  incision,  298 
"       posterior  incision,  299 
"       radial  incision,  301 
Elbow,  Part  V,  Chapter  IV,  256-260 
"      anterior  incision,  260 
"      external  incision,  258 
"      internal  incision,  259 
"      posterior  incision,  257 
"      radial  incision,  258 
"  Finger,  302 

Foot,  180-187 
"      anterior  incision,  185 
"      circular  incision,  186 
"      external  anterior  incision,  181 
posterior  incision,  182 
"      Kocher  incision,  186 
"      metatarsal  incision,  196 
"      phalangeal  incision,  196 
"  "      tarsal  incision,  181-186 

Hand,  302 


INDEX  319 

Arthrotomy,  Hand,  anterior  incision,  300 

"  "       carpal  incision,  298-301 

»  "       external  incision,  301 

"  "       metacarpal  incision,  302 

"  "       Oilier  incision,  298 

"  "       phalangeal  incision,  302 

"  "       posterior  incision,  299 

"  "       radial  incision,  301 

"  Hip,  anterior  incision,  18 

"  "    adductor  incision,  24 

"  "    anterior  "U"  shaped  incision,  23 

«  "    Brackett  antero-lateral  incision,  19 

u  "          "            "          "       with  enlargement,  20 

"  "    Murphy  incision,  22 

"  "   posterior  incision,  21 

"  "    Sprengel's  incision,  14 

"  Knee,  see  Chapter  IV 

"  "    anterior  median  incision,  82 

"  "    bayonet  incision,  84 

"  "    cartilage  semilunar  incision,  78 

"  "    crucial  ligaments,  incision,  85 

"  "    lateral  incision,  85 

"  "    median  incision,  82 

"  "    posterior  incision,  83 

"  "    semilunar  cartilage,  incision,  78 

"  "    "  U "  shaped  incision,  86 

"  Metacarpal  bones,  302 

"  Phalangeal  incision,  302 

"  Sacro-iliac  joint  incision,  15 

"  Semilunar  cartilage  incision,  78 

Shoulder,  228,  231,  Part  IV,  Chapter  IV 

"  "        anterior  incision,  228 

"  "        Burrell  incision,  213 

"  "        Codman  incision,  231 

"  "        Kocher  incision,  230 

"  "        posterior  incision,  229 

Wrist,  297,  303,  Part  VI,  Chapter  III 

"  "     anterior  incision,  300 

"  "     external  incision,  301 

"  "     metacarpal  incision,  302 

"  "     Ollier's  incision,  298 

"  "     posterior  incision,  299 

"  "     radial  incision,  301 
Astragalectomy,  for  dangle  foot,  168 
for  flail  ankle,  168 

"  displacement  of  foot  backward,  168 

"  for  paralytic  cases,  168-170 

"  plaster  of  Paris  for,  170 
Astragalo-scaphoid  arthrodesis,  114 
Astragalus,  see  astragalectomy 

"  bone  operation,  see  club  foot,  pes  cavus,  Jones  operation 

"  drainage  in  suppurative  conditions,  194,  323 

"  circular  incision  for  astragalectomy,  186 

"  lateral  incision  for  astragalectomy,  168 

"  suppurative  conditions  of,  194,  323 

"  tuberculosis  of,  197 


320  INDEX 

B 

Back  brace,  Figs.  470-472 
Bacterial  examination,  Carroll  technique,  323L 
Baer's  chromicized  pig's  bladder  for  arthroplasty,  95 
Bartow  drill  for  silk  ligaments,  Fig.  109 
"     silk  ligament  at  the  knee,  77 
"        "  "  "    "  shoulder,  226 

Bayonet  incision  at  the  knee,  84 
Biceps  femoris,  sec  hamstring 
"      myotomy  of,  69 

"      paralysis  of,  transplantation  of  the  triceps,  250 
"      transplantation  of,  61-67 
Bloodless  operation  for  congenital  hip,  1-2 

"       reduction  of  congenital  hip,  1 
Bow  leg,  53,  317 

"       "   operation,  53 
Bowing  from  rickets,  317 
Bone  graft  for,  316 

"      "    fractures,  see  fractures 
"      "   knee  ankylosis,  94,  95 
"     "   operation  on  the  spine,  Albee,  321 
"      "    spinal  ankylosis,  321,  322 
"      "   ununited  fractures,  see  fractures 
Bone  operations,  see  deformities,  osteotomy,  bone  graft,  suppurative  conditions 
Brackett's  curved  osteotomy,  39 

"         "U"  shape  incision  at  hip,  23 
Bradford's  club  foot  wrench,  Figs.  145,  150,  also  135-141 
congenital  hip  machine,  2 
congenital  hip  machine,  Figs.  1-3 
frame,  Figs.  8-10-9-24 
hip  machine,  2 
"    splint,  474 

subcutaneous  method  of  silk  ligaments,  173 
wrench  for  manipulation  of  the  foot,  102 
Burrell  incision  in  dislocation  of  shoulder,  Fig.  362,  §  213 

c 

Caliper  splints,  Figs.  475-478 
Carrell-Dakin  apparatus,  323M 
"         "     bacterial  test,  323L 
"         "      first  aid  dressing,  3231 
"         "      microscopic  examination,  323L 
"         "      operative  preparation,  323 J 
"      solution,  323A 
"      technique,  3231,  J,  K 
"         "      wound  dressing,  323K 
"         "  "      preparation,  323 J 

Club  foot,  106-113 

"       "    after-treatment,  108 

"       "    Bradford  wrench  for,  102 

"       "    bone  operation,  105 

"       "    Davis  wrench  for,  103 

"       "    excision  of  bone,  105 

"       "    operations,  104-107 

"       "    plaster  of  Paris  for,  Figs.  457,  458,  §  107 


INDEX  321 

Club  foot,  position  for,  107 

"       "    Thomas  wrench  for,  101 
"       "    wrenches,  100-103 

"       "    wrench,  Bradford,  §  102,  Figs.  145-150,  also  Figs.  135-141 
"       "  "       Davis,  103 

"       "  "       Thomas,  101 

Codman  incision  at  the  shoulder,  231 
Compound  fractures,  see  fractures,  suppurative  conditions 
Congenital  dislocation  of  the  hip,  Part  I,  Chapter  I 

"  "  "     "       "    after-treatment,  3 

"  "  "     "       "    apparatus  for,  Figs.  1-3 

"  "  "     "       "    bloodless  reduction,  1 

"  "  "     "       "    Bradford  hip  machine,  2 

"  "  "     "       "  "         frame  for,  3 

"  "  "     "       "  "        method,  3 

"  "  "     "       "    Lorenz  position  for,  Figs.  11-12 

"  "  "     "       "    machine  for  reducing,  Figs.  1-3 

"  "  "     "       "    method  of  treatment,  1 

"  "  "     "       "    Mueller  position  for,  13-14 

"  "  "     '"       "    open  operation,  4 

"  "  "     "       "    Plaster  of  Paris  for,  5 

Congenital  hip,  see  congenital  dislocation  of,  hip 
Contracted  ankle,  see  deformities  of  the 

"        extensors  of  the  fingers,  see  tendon  lengthening 

"        extensors  of  the  wrist,  see  tendon  lengthening 
finger,  280 

"  "      manipulation,  281 

"        flexors  of  the  fingers,  tendon  lengthening,  subperiosteally  at  the  condyle, 
288 

"        flexors  of  the  wrist,  tendon  lengthening,  subperiosteally  at  the  condyle, 
288 

"       hip,  8 

"  "     ankylosed,  38 

"        knee,  see  knee  flexion 

"        shoulder,  manipulation  for,  202 

"        muscles,  myotomy  for,  69-70 

"        tendons,  see  tendon  lengthening 

"        wrist,  280' 
Coxa  vara,  29 

Crucial  ligaments,  operation  for  repair  of,  79 

Cuirass,  plaster  of  Paris  for  the  hip  and  for  the  shoulder,  318,  320,  328,  329     . 
Curved  osteotomy  at  the  hip,  37 
Cushing  knot  for  leg  traction,  Figs.  497-504 
Cut  tendon  of  the  finger,  282 

D 
Dakin-Carrell,  see  Carrell-Dakin,  323 
Dakin  solution,  see  also  Carrell-Dakin,  323 
"  "        chlorine  test  for,  323 

difficulties  of,  323G 
"       lime,  test  for  chlorine  in,  323C,  323D 
"  "       making  solution,  323B 

"  "       solution  formula,  323 A 

"  "  "        preparation,  323B 

test  for,  323E 
"  "       test  for  Dakin  solution,  323E 


322  INDEX 

Dakiu  solution,  test  for  chlorine  in  lime,  323C 

"  "  "     "  "         "  Dakin  solution,  323E 

Dangle  foot,  16S 
Davis  club  foot  wrench,  103 

"     foot  wrench,  for  manipulation  of  the  foot,  103 
Deformity,  ankle,  sec  ankle  deformity 
elbow,  see  elbow  deformity 
femur,  see  femur  deformity 
finger,  see  finger  deformity 
foot,  see  foot  deformity 
hand,  see  hand  deformity 
hip,  see  hip  deformity 
humerus,  see  humerus  deformity 
infantile  paralysis,  see  paralysis  deformity 
knee,  see  knee  deformity 

poliomyelitis,  see  elbow,  foot,  hand,  hip,  knee  and  wrist 
rachitic,  see  rickets  deformity 
rickets,  317 

"       bow  leg,  see  bow  leg  deformity 
"       knock  knee,  see  knock  knee  deformity 
shoulder,  see  shoulder  deformity 
tibia,  see  tibia  deformity 
toe,  see  toe  deformity 
wrist,  see  wrist  deformity 
Dislocation,  clavicle,  210 

elbow,  Part  V,  Chapter  I,  also  247,  265 

elbow,  irreducible,  265 

hip,  congenital,  Part  I,  Chapter  I,  also  see  congenital  dislocation  of  the 

hip 
hip,  congenital,  plaster  of  Paris,  331 
patella,  92 

shoulder,  Part  IV,  Chapter  I 
"        capsulorrahphy,  214 
"        irreducible,  213 
"        in  obstetrical  paralysis,  211 
"        recurrent,  215 
Displacement  of  the  foot  backward,  astragalectomy,  168 
Displaced  semilunar  cartilage,  78 
Drill,  Bartow,  Fig.  109 

E 

Elbow  ankylosis,  269,  also  Part  V,  Chapter  V 
"  "        arthroplasty  for,  271,  272 

"  "        excision  for,  269 

"  anterior  incision,  260 

"  arthrodesis,  255 

"  arthroplasty,  271,  272 

"  arthrotomy,  Part  V,  Chapter  IV,  256-260 
"  "  anterior  incision,  260 

"  "  external  incision,  258 

"  "  internal  incision,  259 

"  "  posterior  incision,  257 

"  "  radial  incision,  258 

"  deformity,  Part  V,  Chapter  I,  see  ankylosis,  269,  see  dislocation,  247 
"  "         from  fracture,  see  fractures,  261-267 


INDEX  323 

Elbow  deformity,  manipulation  for,  248 

"  "         see  osteotomy,  204 

"  dislocation,  Part  V,  Chapter  I 

"  "           irreducible,  265 

"  excision  for  ankylosis  of,  269 

"  "         "  suppurative  conditions,  276 

"  external  lateral  incision,  258 

"  fascia  transplantation,  253 

"  flail,  251,  252-253 

"  "     arthrodesis,  255 

"  "     silk  ligaments  for,  252 

"  fracture,  261-267 

"  "        both  arms,  266 

deformity,  261-267 

"  "        of  the  olecranon,  267 

"  "        overlapping,  266 

"  "        traction  apparatus  for,  262 

"  "        ununited,  264 

"  incision,  anterior  incision,  260 

"  "       external  incision,  258 

"  "       internal  incision,  259 

"  "       posterior  incision,  257 

"  "       radial  incision,  258 

"  infantile  paralysis,  see  deformities,  flail  elbow,  muscle  transplantation,  paraly- 
sis 

"  internal  lateral  incision,  259 

"  Jones  operation,  254 

"  manipulation,  248 

"  multiple  fractures,  265 

"  muscle  transplantation,  see  paralysis,  muscle  transplantation 

"  operation,  overhead  sling,  273 

"  osteomyelitis,  275,  323,  also  see  suppurative  conditions  at  the  elbow 

"  overhead  sling  in  operations  on  the,  273 

"  overlapping  fracture,  263 

"  paralysis,  see  paralysis,  muscle  transplantation,  also  251-253 

"  plaster  of  Paris  for,  249 

"  poliomyelitis,  see  deformities,  flail  elbow,  muscle  transplantation,  paralysis 

"  posterior  incision,  257 

"  preparation  of  the  skin  for  operation,  345 

"  puncture,  268 

"  silk  ligaments,  252 

"  skin  operation,  254 

"  skin  preparation  for  operation,  345 

"  sling  overhead  in  operations  on,  273 

"  subluxation,  247,  262-265,  see  fracture 

"  suppurative  conditions,  323,  also  Part  V,  Chapter  V,  also  274-277 

"  synostosis,  270 

"  tapping,  268 

"  tendon  transplantation,  see  muscle  transplantation 

"  traction  apparatus  for  operations  on  or  fractures  of,  262 

"  tuberculosis,  excision  for,  276 

"  ununited  fractures,  264 
Elongation  of  the  tendon  in  the  finger,  282 
Equino  valgus,  109,  114 

"  "       bone  operation  for,  111 

"  "       Bradford  wrench  for  manipulation  of,  102 


324  INDEX 

Equino  valgus,  Davis  wrench  for  manipulation  of,  103 
"       Thomas  wrench  for  manipulation  of,  101 
"  "       manipulation,  99 

"  "       plaster  for,  113 

"  "       position  for,  113 

"       Thomas  wrench  for,  101 
"  "       tilting  of  the  oscalcis  in,  112 

"      wrenches  for,  101,  102,  103 
"     varus,  106 

"  "     after-treatment,  108 

"  "     bone  operation  for,  105 

"     Bradford  wrenches  for,  Fig.  102 
"  "     Davis  wrench  for,  103 

"  "     manipulation  for,  99 

"     Ober  operation  for,  106 
"  "     operations  for,  104,  105,  106 

"  "     plaster  of  Paris  for,  337 

"     position  for,  113 
"  "      Thomas  wrench  for,  101 

Equinus,  117,  see  manipulation  of  the  foot 
"      fascia  transplantation,  178 
"      fractures,  old,  with  equinus,  117,  129 
"      operation,  129 
"      plaster  of  Paris  bandage,  131 
"      silk  ligaments  for,  171,  172,  173 
"      wrenches  for,  101-103 
Excision  for  elbow  ankylosis,  269 

"         "         "     suppurative  conditions  of,  274 
"         "         "     tuberculosis  of,  276 

"   hip,  44 
"         "      "in  suppurative  conditions,  12-45,  323 
"         "       "  partial,  in  osteo-arthritis,  painful,  40 
"        "   knee  to  obtain  ankylosis,  94 
"   shoulder,  239-240 

"      in  suppurative  conditions,  244 
"   wrist,  311 

"         "     after-treatment,  311 
"         "         "     ankylosis,  311 
"         "         "     anterior  and  posterior  excision,  311 

"    Ollier's  method,  311 
"         "         "     in  suppurative  conditions,  309,  310,  311 
Exposure  of  the  joints,  see  arthrotomy 
Extensor,  finger,  tendon  shortening,  290 

"     contracted,  tendon  lengthening,  285 
"         lengthening  by  subperiosteal  operation  at  the  condyle,  286 

longus  digitorum  contracture,  119,  120,  121 
"  "  "        operation,  119,  120,  121 

shortened,  119,  120,  121 
tenotomy,  119,  120,  121 
"  "        transplantation,  292 

"      pollicis  transplantation,  292 
wrist,  contracted,  tendon  lengthening,  285 
"  "    tendon  shortening,  290 

External  incisions,  see  arthrotomy 


INDEX  325 

F 

Fascia  transplantation,  ankle  for  equinus,  178 
"  "  elbow,  253 

"  "  equinus,  178 

"  "  toe  drop,  178 

"      removal  from  the  thigh,  253 
Fasciotomy,  hip,  8 

"  plaster  of  Paris  after,  332 

Femur  bowing,  188,  53,  55 

"      deformity,  53,  see  hip,  deformity  of  the,  see  knee  deformity 

"      fractures,  25-28 

"  "        overlapping,  26 

"      length  adjustment,  42 

"      osteomyelitis,  43,  44,  45,  46,  47,  323 

"      osteotomy  for  bowing,  188 

Gant,  37 
"  "         for  hip  deformity,  37 

"  "         for  knee  deformity,  55 

"  "         McCewen,  55 

Fibula,  189 

"       bowing,  53,  188 
"       deformity,  188 
"       fractures,  190 
"  "         overlapping,  189 

"       osteomyelitis,  198 
"       osteotomy,  188 
"       suppurative  conditions,  194 
Finger  ankylosis,  arthroplasty  for,  308 
"      apparatus,  Figs.  442,  446 
"  "         after  operation,  333 

"      arthrotomy,  302 
"      contracted,  280 
"      contracted,  manipulation,  281 

"      flexors,  contracted,  tendon  lengthening  subperiosteal^/  at  the  condyle,  288 
"     fracture,  303-304 
"  "        ununited,  304 

"      incision,  302 
"      manipulation,  281 
"      retaining  apparatus,  323,  Figs.  442-446 
"      silk  elongation  for  cut  tendon,  282 
"      suppurative  bone  disease,  309 
"      tendon  cut,  silk  elongation,  282 
First  aid  dressing,  Carrell  method,  3231 
Flail  ankle,  168,  also  see  Chapter  III 
"  "    arthrodesis  for,  179 

"  "    astragalectomy  for,  168 

"    muscle  transplantation  for,  168 
"    silk  ligaments  for,  171,  172,  173 
"  "    tendon  transplantation  for,  168 

"     elbow,  251,  252,  253,  254,  255,  also  Part  V,  Chapter  III 
"         "       arthrodesis  for,  255 
"        "       silk  ligaments  for,  252 
"    hip,  8-10 

"       "     arthrodesis  for,  12 
"      "    silk  ligaments  for,  13 


326  INDEX 

Flail  knee,  75,  76,  77 
"         "     arthrodesis  for,  75 
"         "     patella,  fixation  for,  76 
"        "     silk  ligaments  for,  77 

'    shoulder,  223 

"        arthrodesis  for,  225 
"        silk  ligaments  for,  226 
carsus,  astragalo-scaphoid  arthrodesis  for,  114 
Flat  foot,  109-114 
"        "  bone  operation  for,  111 
"         "   Bradford  wrench  for,  102 
"         "  Davis  wrench  for,  103 
"         "  excision  of  bone  for,  111 
"         "  manipulation  of,  99 
"        "  plaster  of  Paris  for,  113 
"         "  position  for,  113 

"        "  tilting  of  the  oscalcis,  operation  for,  112 
"         "  Thomas  wrench  for,  101 
"         "  WTench  for,  100 
Flexed  hip,  bone  operation  for,  37 

"         "    fasciotomy  for,  8 

"        "    Gant  operation  for,  37 

"         "    manipulation  for,  7 

"        "    osteotomy  for,  39 

"         "    Soutter  operation  for,  8 

"         "    transplantation  of  hip  flexors  for,  8 

"      knee,  bone  operation  for,  54 

"  "    genuclast  for,  51 

"  "    manipulation  for,  48 

"  "    myotomy  for,  71 

"  "    osteotomy  for,  54 

"  "     tenotomy  for,  70-74 

Flexor  of  fingers  contracted,  tendon  lengthening  subperiosteally  at  the  condyle,  288 

"       "  finger,  tendon  lengthening,  287 

"       "       "  "      shortening,  289 

"      "  wrist,  contracted,  tendon  lengthening  subperiosteally  at  the  condyle,  288 

"       "       "     tendon  lengthening,  287 

"       "       "  "      shortening,  289 

Foot,  ankylosis  of;  arthroplasty,  192 

"    ankylosis;  astragalectomy,  168 

"    arthrodesis,  179 

"    arthrotomy,  180-187 

"    arthrotomy,  anterior  external  incision,  181 

"  "  "        internal  incision,  183 

"  "  "        median  incision,  185 

"  "  circular  incision,  186 

"  "  Kocher  incision,  186 

"  "  metacarpal  incision,  302 

"  "  posterior  external  incision,  182 

"  "  posterior  internal  incision,  184 

"    arthroplasty,  192 

"    astragalectomy,  168 

"    Bradford  silk  ligament,  173 

"    bone  operation  for  cavus,  116 

"    bone  operation  for  club  foot,  105 
""  "         "  valgus,  111 


INDEX  327 

Foot,  bone  operation  for  varus,  105 

"  calcaneus,  115 

"  caliper  splint,  Fig.  477 

"  circular  incision,  186 

"  claw  foot,  118-124 

"  club  foot,  104-108 

"  contracted  tendons,  118-124 

"  contracted  toes,  claw  foot,  118-124 

"  dangle,  168,  179 

"  deformities,  see  varus,  valgus,  cavus,  equinus,  see  Part  III,  Chapters  I-III 

"  "         equinus,  117,  129 

"  "         equino  valgus,  109,  114 

"  "    varus,  104,  105,  106,  107,  108 

"  excision,  168,  195,  197 

"  flail,  179 

"  flat  foot,  109-114 

"  fracture,  117,  187-190 

"  hammer  toe,  claw  foot,  118,  124 

"  hallux  valgus  and  foot  deformity,  125 

"  incision,  see  arthrotomy 

"  infantile  paralysis,  see  deformities,  paralysis,  transplantation 

"  joint,  tibio- tarsal,  complete  exposure  for,  186 

"  manipulation  with  Bradford  wrench,  102 

"  "            "    club  foot  wrench,  101-103 

"  "            "   Davis  wrench,  103 

"  "            "   flat  foot  wrench,  101,  103 

"  "            "   Thomas  wrench,  101 

"  muscle  transplantations,  in,  see  paralysis,  muscle  transplantation 

"  Ober  operation  for  club  foot,  106 

"  osteomyelitis,  198,  323 

"  paralytic  conditions  of,  151-164,  166 

"  plaster  of  Paris  for,  Figs.  451-456,  see  under  each  operation 

"  poliomyelitis,  see  deformities,  paralysis 

"  posterior  external  incision,  182 

"  posterior  internal  incision,  183 

"  Potts  fracture  deformity,  117 

"  preparation  of  the  skin  for  operation,  341 

"  puncture  of  the  ankle  joint,  191 

"  silk  ligaments,  subcutaneous  method,  173 

"  "          "          by  open  method,  172 

"  supports,  Figs.  477,  479,  480 

"  suppurative  conditions,  194-201,  323 

"  tapping  of,  191 

"  tendon  fixation,  174 

"  "     lengthening,  138-140 

"  "     shortening,  144,  148 

"  "     transplantation,  see  muscle  transplantation,  see  paralysis 

"  tuberculosis,  197 

"  valgus,  109-113 

"  varus,  104-109 

"  weak,  171,  172,  173,  Chapter  III 

"  wrenches,  Bradford,  102 

club  foot,  101-103 

"  "        Davis,  103 

flat  foot,  101,  103 

"  "        Thomas,  101 


328  INDEX 

Forearm,  apparatus  to  prevent  inward  rotation,  Fig.  395 
"        bowing  of,  317 
"        deformity  of,  317 
"        fractures  of,  261 

"        fractures  of  both  bones  overlapping,  266 
"        muscle  transplantation  in  the,  284 
Formaldehyde  glycerine  solution  for  injection  into  the  joint,  33 
Fracture,  ankle,  117,  also  187-190 

"        bones  both  of  the  forearm,  266 
"        carpus,  304 

"        compound,  see  suppurative  conditions 
"       deformity  from,  see  each  joint,  each  bone 
elbow,  261-267 
"      multiple,  265 
"  "      traction  apparatus  for,  262 

femur,  25-28 
"  "      in  infants,  apparatus  for,  Figs.  67-70 

"  "      neck,  plaster  of  Paris  cuirass  for,  329 

"  "      overlapping,  26 

"  "      traction  apparatus  for,  37,  Figs.  54-57 

fibula,  190 
"        fibula,  overlapping,  189 
"        finger,  303-304 

foot,  in  the,  187-190 
"       forearm,  both  bones,  266 
hand,  303-304 
hip,  25,  26,  27,  28 
"  "    compound,  27 

"  "    at  the  neck,  28 

"  "    ununited,  27 

"  "    plaster  of  Paris  cuirass,  for,  329 

"  "    traction  apparatus  for,  37,  Figs.  54,  57 

humerus,  232,  233 
"  "         overlapping,  263 

"  "        traction  apparatus  for,  235,  also  262 

"  "        ununited,  237 

"       knee  cap,  90 
"       knee  joint,  91 

leg,  190 
"       neck  of  the  femur,  plaster  of  Paris  cuirass  for,  329 
"       neck  of  the  femur,  28 
"       olecranon,  267 
"       patella,  90 
radius,  266 
shoulder,  232-237 
"  "        traction  apparatus  for,  235,  also  Figs.  375,  378 

shoulder,  237 
tibia,  189 
"       ulna,  266 

"       Whitman  treatment  for  fracture  femoral  neck,  28 
"       wrist,  303-304 
Frame,  Bradford,  Figs.  8,  9,  10,  24 

"       portable  for  jackets,  plaster  of  Paris,  Fig.  469 


INDEX  329 

G 

Galli  tendon  fixation,  174,  175,  176,  177 
Gant  operation  at  the  hip,  37 
General  considerations,  infantile  paralysis,  319 
Genuclast,  Fig.  72 

Goldthwait,  51,  also  Fig.  72 

"         for  subluxation  of  the  knee,  51 
Gluteal  bursitis,  incision  for,  32 
Glycerine  formaldehyde  antiseptic  injection,  33 
Goldthwait  genuclast,  51,  also  Fig.  72 
Gracillis  myotomy,  69 

"     transplantation,  see  muscle  transplantation,  see  hamstring 

H 

Hallux  valgus,  125 

"  "      after-treatment,  125 

Hammer  toe,  118-124 

"         "   bone  operation  for,  123 

"         "   excision  of  the  joint  for,  124 

"   tendon  operation  for,  119,  120,  122 
Hamstring  muscles  transplantation  forward,  61-62 

"  "  transplantation,  see  muscle  transplantation 

"         tenotomy,  69-70 
Hand  ankylosis,  arthroplasty  for,  307 
"         excision  for,  311 
anterior  incision,  300 
apparatus  after  operation  on,  333 
arthroplasty  for  ankylosis,  307 
arthrotomy,  297-302 

"  anterior  incision,  300 

"  external  incision,  301 

"  metacarpal  incision,  302 

"  Oilier  incision,  298 

"  posterior  incision,  299 

"  radial  incision,  301 

club  hand,  279 

congenital  deformity,  278-280 
contracted  fingers,  280 

"        tendons,  281,  282,  285,  286-288 
"        wrist,  280 
cut  tendons,  282 
deformity,  Part  VI,  Chapter  I 
club  hand,  279 
"  Madelung,  278 

"  pronation,  283 

"         Tubby  operation  for,  283 
"         wrist  manipulation  for,  281 
dislocation,  278 
excision  of  the  carpus,  311 
excision  for  ankylosis,  306-308,  311 
excision  in  suppurative  conditions,  311 
external  incision,  301 
flexed,  280 

flexors  contracted,  tendon  lengthening  subperiosteally  at  the  condyle,  288 
fractures,  carpal,  303-304 


330  INDEX 

Hand  incisions,  anterior,  300 
"  external,  301 

"  metacarpal,  302 

"         Oilier,  298 
"  phalangeal,  302 

"  posterior,  299 

radial,  301 
infantile  paralysis,  see  deformities,  muscle  transplantation,  deformities  muscle 

and  tendon  operations 
manipulation  for  the,  2S1 
Madelung  deformity,  278 
osteomyelitis,  Part  VI,  Chapter  V,  323 

poliomyelitis,  see  paralysis,  deformities,  muscle  transplantation 
preparation  of  the  skin  for  operation,  346 
pronation  deformity,  283 

pronation  deformity,  muscle  transplantation,  Tubby  operation  for,  283 
puncture,  305 
retaining  apparatus,  333 
rachitic  deformity,  317  . 
silk  extension  for  cut  tendons,  282 
suppurative  conditions,  Part  VI,  Chapter  V,  323 
tendon  elongation,  287 
tendon  lengthening,  285,  287 
tapping  the,  305 
tendon  shortening,  289,  290 
tendon  silk  extension,  282" 
tendons  cut,  282 

Tubby  operation  for  pronation  of  the,  283 
tuberculosis,  see  suppurative  conditions 
Hawley  table,  37 

Head,  plaster  of  Paris  bandage  for,  326 
Hibbs  operation  for  obtaining  ankylosis  of  the  spine,  320 
High  scapula,  216 

Hip  abduction  and  flexion  deformity,  6,  7,  36,  37 
"  adduction  and  flexion  deformity,  6,  7,  36,  37 
"   ankylosis  of,  34-37 

"  "      with  flexion  and  adduction,  36 

"  arthritis  in  infancy,  acute,  46 
"   arthrodesis,  40 
"   arthroplasty,  34 
"   arthrotomy,  adductor  incision,  24 
"  "  anterior  incision,  18 

"  "  antero-lateral  incision,  19 

"  "  anterior  "U"  incision,  23 

"  "  Brackett  incision,  23 

"  "  Murphy  incision,  22 

"  "  posterior  incision,  21 

"  "  Sprengel's  incision,  14 

"  Bradford  congenital  hip  operation,  2 

"  machine,  2 
"  coxa  vara,  29,  38 

"  deformity,  see  subluxation,  flexion,  dislocation,  abduction,  adduction,  coxa  vara, 
"       bowing  and  fracture. 
"   dislocation,  congenital,  1 
"  "  bloodless  operation,  1 

"  "  open  operation,  4 


INDEX  331 


Hip  dislocation,  plaster  of  Paris  for,  5 

"  epiphysis,  separation,  41 

excision,  44 
fasciotomy,  8 
flail,  11 

flexion,  6,  7,  8,  also  see  Soutter's  operation 
"       with  abduction,  36 
"  "     ankylosis,  36 

"  "     dislocation,  36,  also  see  congenital  hip 

"       without  dislocation,  36 
"       due  to  contracted  soft  tissues,  6 
"       operation,  37 
flexors  transplanted,  see  transplantation  of  hip  flexors,  8 
fracture,  25,  26,  27,  28 

"       of  the  neck,  28 
Gant  operation,  37 
neck,  28 
overlapping,  26 
ununited,  27 
incision,  adductor,  31 
"       anterior,  18 
"       antero-lateral,  19 
"       antero-lateral  with  enlargement,  20 
"       anterior  "U"  shape,  23 
"       Brackett's  "U,"  23 
"      internal,  24 
"       posterior,  21 
"       "U"  shape,  22 
"       Sprengel's,  14 
Hip  joint,  tapping,  33 
machine,  2 

Bradford,  2 
"        for  traction  during  operations  on  the  hip  or  leg,  2 
"        congenital,  Figs.  1-3 
"        for  traction,  during  operation,  2 
manipulation,  6 
muscle  transplant  hip  flexors,  8 
myotomy  for  spastic  contractures,  71-73 
operation,  tense  adductor  magnus,  31 
osteo-arthritis,  40 
osteomyelitis,  323,  47 
osteotomy  at  the  neck,  39 

"  subtrochanteric,  37 

plaster  of  Paris,  330 
plaster  of  Paris  for  congenital,  331 
"       "       "     after  fasciotomy,  332 
"       "       "     after  osteotomy,  10 

"       "       "     after  transplantation  of  the  hip  flexors,  8 
"       "       "     cuirass,  329 
preparation  of  the  skin  for  operation,  347 
rickets,  29 
silk  ligaments,  13 
Soutter  operation,  8 
splint,  Figs.  473,  474 

suppurative  conditions,  43,  44,  45,  46,  47,  also  323 
tendon  transplantation  see  muscle  transplantation 


332  INDEX 

Hip  traction  during  operations,  Fig.  55-61 
"  "      apparatus,  Figs.  55-61 

"  transplantation  of  the  hip  flexors  at  the  ilium, 
Hoffa's  curved  bsteotomyj  37 
Hollow  foot,  116 

Humerus  deformity  from  fracture,  237 
"        dislocation,  210 
"        excision  of  the  elbow,  269-276 

"     "  shoulder,  239,  240 
fracture  deformity,  204,  232,  233 
"  "        elbow,  264 

"  "        overlapping,  263 

"       ununited,  264 
"  "        supracondylar,  261-262 

"  "        traction  apparatus  for,  235,  262 

"        inward  rotation,  203 
"        osteotomy  for  inward  rotation,  204 
"  "  "  deformity,  204 

"        osteomyelitis,  242-244 
"        overlapping  fracture,  236 
"        plaster  of  Paris  for,  217 
"  "      "        "    cuirass  for,  328 

"        suppurative  conditions,  243,  323 
wire  shelf  for,  Figs.  314,  315 


Ilium  exposure,  14 
Incision,  14 

ankle,  181-186 
"  "     anterior  median,  185 

"  "     circular,  186 

"  "     external  anterior,  181 

"  "  "      posterior,  182 

"  "     internal  anterior,  183 

"  "  "      posterior,  184 

"     Kocher,  186 
"  "     tarsal,  181-185 

"  "     and  foot,  Part  III,  Chapter  IV 

carpal,  298-301 
"  "      anterior,  300 

"  "      external,  301 

"      Oilier,  298 
"  "      posterior,  299 

"      radial,  301 
"       elbow,  Part  V,  Chapter  IV,  256-260 
■ "  "       anterior,  260 

"  "       external,  258 

"       internal,  259 
"  "       posterior,  257 

"  "       radial,  258 

finger,  302 
"       foot,  181-186 
"  "     anterior,  181 

"  "     circular,  186 

"  "     external  anterior,  181,  183 

"  "  "      posterior,  182,  184 


INDEX  333 

Incision,  foot,  Kocher,  186 

"     metatarsal,  196 
"     phalangeal,  196 
"     tarsal,  181-185 
hand,  302 

"      anterior,  300 
"      carpal,  298-301 
"      external,  301 
"      metacarpal,  302 
"      Oilier,  298 
"      phalangeal,  302 
"      posterior,  299 
"      radial,  301 
hip,  anterior,  18 
"   adductor,  24 
"   anterior  "U"  shaped,  23 
"   Brackett  antero-lateral,  19 
"  "  "  "     with  enlargement,  20 

"    Murphy,  22 
"   posterior,  21 
"   Sprengel's,  14 
knee,  see  Chapter  IV 
"     anterior  median,  82 
"     bayonet,  84 
"     cartilage  semilunar,  78 
"     crucial  ligaments,  79 
"     lateral,  85 
"     median,  82 
"     posterior,  83 
"     semilunar  cartilage,  78 
"     "U"  shaped,  86 
metacarpal  bones,  302 
phalangeal,  302 
sacro-iliac  joint,  15 
semilunar  cartilage,  78 
shoulder,  228,  231,  Part  IV,  Chapter  IV 
anterior,  228 
Burrell,  213 
Codman,  231 
Kocher,  230 
posterior,  229 
i  it,  297,  303,  Part  VI,  Chapter  III 
anterior,  300 
external,  301 
metacarpal,  302 
Ollier's,  298 
posterior,  299 
radial,  301 
Infantile  paralysis,  319  and  under  each  joint,  see  muscle  transplantation,  see  muscle 

and  tendon  operations 
Infra  spinatus  shortening,  206 
Instruments,  Bartow  drill,  Fig.  109 

"  Bradford  foot  wrench,  102 

club  foot  wrench,  101,  102,  103 
"      "  "       Bradford,  102 

"      "  "      Davis,  103 


334 


INDEX 


Instruments,  club  foot  wrench,  Thomas,  101 
Davis  foot  wrench,  103 
foot  wrench,  Figs.  121-154 
genuclast,  Fig.  72 

"         Goldthwait,  Fig.  72 
Goldthwait  genuclast,  Fig.  72 
needle  for  subperiosteal  insertion  of  silk,  91 
osteotome,  good  and  poor,  Figs.  494-496 
periosteal  needle,  Figs.  91,  281 
tendon  carrier,  Fig.  80,  also  Fig.  230 
tenotome,  good  and  poor,  Figs.  208-209 
Thomas  foot  wrench,  Figs.  121-131 
Inward  rotation,  shoulder  due  to  spastic  paralysis,  209 
"  "  "        muscle  lengthening,  207 

"  "  "        muscle  shortening,  206 

"  "  "       obstetrical  paralysis,  208 

"  "  "       obstetrical,  see  obstetrical  paralysis 

"  "  "       operation  for,  203 

"  "  "       osteotomy  for,  204 

"  "  "       Sever's  operation,  208 

Irreducible  dislocation  elbow,  265,  also  see  dislocation 
"  "         shoulder,  213,  also  see  dislocation 


Jacket,  plaster  of  Paris,  327 

"  "       "         "    portable  frame  for,  Fig.  469 

Jaw  ankylosis,  arthroplasty,  318 
Joint,  see  ankle,  elbow,  hip,  knee,  shoulder,  wrist 

"      antiseptic  injection,  33 
Jones  operation  at  the  elbow,  254 

"      operation,  116 

E 

Knee  ankylosis,  Chapter  V 
"  arthroplasty,  95 
"  arthrodesis  for,  75 
"   arthrotomy,  Chapter  IV,  §§  80,  81 
"   anterior  median,  82 
"  bayonet,  84 
"   crucial  ligament  for,  79 
"   lateral,  85 
"   median,  82 
"   posterior,  83 
"   semilunar  for,  78 
"   "U"  incision,  86 
"   Bartow  silk  hgament  for,  77 
"   caliper  sphnt,  Figs.  475-476 
"    crucial  ligament,  79 
"   fractures,  patella,  90 
"  "         overlapping  of  femur  or  tibia,  88 

"         ununited,  89 
"   deformity,  55,  also  Chapter  I 

"         correction  with  genuclast,  51 
"  "         osteotomy,  54 

"        tendon  lengthening,  50 


INDEX  .335 


Knee  dislocation  patella,  92 
excision  for,  94,  98 
exposure,  "U"  shape  incision,  86 
flail,  75 
flexion,  48  also  51 

"       correction  with  genuclast,  51 
"       deformity,  Osgood's  operation,  59 
"       tendon  lengthening,  50 
•  "       osteotomy,  54 
incision,  see  arthrotomy 

"       adductor  tendon  for,  31 
internal  derangement,  79,  also  see  arthrotomy 
joint  fractures,  91 
joint  puncture,  93 
joint  tapping,  93 
manipulation,  48 

muscle  transplantation,  see  paralysis,  muscle  transplantation 
muscle  rupture,  60 
myotomy,  69-71 

osteomyelitis,  97,  98,  99,  also  323 
operative  preparation  of  the  skin,  342 
osteotomy  for,  54,  55 
patella  dislocation,  92 
plaster  of  Paris  after  manipulation,  335 
"      "         "   preventing  rotation,  58 
"       "         "   after  operation,  334 
preparation  of  the  skin  for  operation,  341-342 
rachitic  deformities,  53 
semilunar  cartilage,  73 
silk  ligaments,  77 
subluxation,  51 

"  manipulation,  51-52 

"  genuclast  for,  51 

suppurative  conditions,  96,  97,  98,  99,  also  323 
suppurative  conditions  and  osteomyelitis,  323 
tendon  transplantation,  see  muscle  transplantation 
tenotomy,  70,  74 
Knife  for  plaster  of  Paris,  Fig.  462 
Knock  knee,  53 

"        "    operation,  53 
Knot  for  leg  traction,  Figs.  497,  504 
Kocher  incision  at  ankle,  186 
"  "       "   shoulder,  230 

L 
Lacing  of  a  plaster  of  Paris,  325 

Lange  method  of  muscle  and  tendon  transplantation,  148 
Leg,  plaster  of  Paris  for,  Fig.  461 
"    preparation  of  the  skin  for  operation,  341 
"    traction  apparatus  for  operations  on  the,  37 

M 

Machine  for  congenital  dislocation  of  the  hip,  Bradford,  2 
Madelung's  deformity,  278 
Manipulation,  elbow,  248 
"  finger,  281 


330  INDEX 

Manipulation,  foot,  99 

"  "   apparatus  for,  100 

"  Bradford  wrench  for,  102 

"  "   Davis  wrench  for,  103 

"  "   deformity,  99 

"  "   Thomas  wrench,  101 

"  "  plaster  of  Paris  following,  107 

"  hand,  plaster  of  Paris  following,  281 

"  hip,  under  anaesthesia,  7 

knee,4S-50 

"  "     plaster  of  Paris  following,  57,  335 

"  "     subluxation  for,  51-52 

"      shoulder  joint,  202 

"      wrist,  281 
Martin's  traction  in  overlapping  fractures  at  the  arm,  236 

«  u  it  «  «  <<        «      |egj    jgg 

"      "  "  "        "     "    thigh,  26 

Metacarpal  and  phalangeal  ankyloss,  308 
"  arthroplasty,  308 

arthrotomy,  302 
"  bone  incision,  302 

"  contracted  tendon,  382 

"  cut  tendon,  382 

"  incision,  302 

"  joint  incision,  302 

"  silk  tendon  elongation,  382 

"  tendon  elongation,  382 

Metatarsal  suppurative  conditions,  312 

"  and  phalangeal  ankylosis,  123,  124 

arthrotomy,  196 
bone  incision,  196 
contracted  tendon,  119,  121 
cut  tendon,  382 
deformity,  118-124 
excision,  124 
osteotomy,  123 
oste-ectomy,  124 
silk  tendon  elongation,  382 
suppurative  conditions,  196 
tendon  elongation,  382 
Motions  of  the  shoulder,  normal,  202 
Multiple  suppurative  conditions,  312 
Murphy's  arthroplasty  at  the  elbow,  271,  272 
"     "    hip,  34,  35 
"     "    knee,  95 
"     "    shoulder,  241 
"  solution  for  antiseptic  injection  into  the  joint,  93 

"  "TJ"  shaped  incision  at  the  hip,  22 

Muscle  insertion,  Vulpius,  150 

"     operations,    see   muscle   transplantation,    tendon   lengthening   and   muscle 
shortening 
Muscle  operations  at  the  elbow,  Part  V,  Chapter  II 
"     "    finger,  Part  VI,  Chapter  II 
"     "    foot,  Part  III,  Chapter  II 
"  "     "    hip,  Part  I,  Chapter  II 

"     "    knee,  Part  II,  Chapter  II 


INDEX  337 

Muscle  operations  at  the  wrist,  Part  VI,  Chapter  II 
"     rupture,  60 
"     section  removed  from,  73 
"     shortening,  infra  spinatus,  206 

"  "         inward  rotation  of  the  shoulder,  206,  207 

"  "  leg,  in  the,  144 

"  "  long  flexors  of  the  fingers,  289 

"  "         long  flexors  of  the  wrist,  290 

"     transplantations,  biceps,  paralysis,  250 
"  "  elbow,  paralysis,  Part  V,  Chapter  II 

"  "  of  the  extensor  carpi  radialis,  for  paralysis  of  the  flexors,  295 

"  "  of  the  extensor  longus  digitorum,  155,  156,  158,  159 

"  "  "     "  "  "  "  to     the     heads     of     the 

metatarsal,  157,  159 
"     and  tendon  transplantations  of  the  extensor  longus  digitorum  in  the  lower 
third  of  the  leg,  156 
Muscle  and  tendon  transplantations  of  the  extensor  longus  digitorum  to  the  tarsus, 

155 
Muscle  and  tendon  transplantations  of  the  extensor  longus  digitorum  to  the  metatar- 
sal heads,  159 
Muscle  and  tendon  transplantations  of  the  extensor  longus  hallucis,  153,  154,  157 
Muscle  and  tendon  transplantations  of  the  extensor  longus  hallucis  to  the  heads  of 

the  metatarsal,  157 
Muscle  and  tendon  transplantation  of  the  extensor  longus  hallucis  in  the  lower  third 

of  the  leg,  153 
Muscle  and  tendon  transplantation  of  the  extensor  longus  hallucis  to  the  tarsus,  154 
"         "         "  "  "     "       external  hamstring,  65 

"         "  "  "     "       finger  paralysis,  282 

"     "  "     cut  tendon,  282 

"         "         "  "  "     "       flexor  carpi  radialis  for  paralysis  of  the 

flexor  longus  pollicis,  294 
Muscle  and  tendon  transplantations  of  the  flexor  carpi  ulnaris  for  paralysis  of  the 

flexors  of  the  wrist,  295 
Muscle  and  tendon  transplantations  of  the  flexor  longus  digitorum,  152 

"        "        "  "  "    "        "  "  "  to     the     tendo 

Achilles,  163 
Muscle  and  tendon  transplantations  in  the  forearm,  284 

"  "  "     "  "       nerve  supply,  292,  296 

"         "         "  "  "     "  "       for   paralysis   in    the    extensor 

longus  pollicis,  292 
Muscle  and  tendon  transplantations  of  the  gracillis,  61-67 

"        "         "  "  "     "   hamstring  muscles  forward  to  the  quad- 

riceps, 61-62 
Muscle  and  tendon  transplantations  at  the  hip,  Chapter  II,  Part  I 
"         "         "  "  of  "       "   flexors  at  the  ilium,  8 

"        "        "  "  at  the  ilium,  8 

"     "   knee,  Chapter  II,  Part  II 
"  "  "     "       "     Lange  method,  148 

"  "  "    "  nerve  supply  in  the  forearm,  292,  296 

"        "        "  "  of  the  palmaris  longus,  291 

"  "  "     "  "  "     for  paralysis  of  the  ex- 

tensor pollicis,  291 
"        "         "  "  for  paralysis  of  the  fingers,  284 

"         "         "  "  in  paralysis  of   the  tibialis  anticus,    148-160 

"        "         "  "  of  part  of  the  tibialis  anticus  to  the  extensor  of 

the  great  toe,  166 


338 


INDEX 


Muscle  and  tendon  transplantations  of  the  pectoralis  major  for  paralysis  of  the  del- 
toid, 221 
Muscle  and  tendon  transplantations  of  the  pectoralis  major  to  the  trapezius,  220 
"        "  "  "     "   peroneii,  148 

"         "  "  "     "  "        to  the  front  of  the  foot,  148 

"         "  "  "     "  "       Lange  method,  148 

"         "         "  "  "     "  "        post-operative  plaster,  149 

"    '  "  "     "  "        to  the  tendo  Achilles,  165 

"  "  "     "  "        tenotomy  of  the,  138 

"  "  "     "    sartorius,  61,  63,  67 

"         "         "  "  "     "   semi-membranosis,  61-67 

"         "         "  "  "     "   semi-tendonosis,  61-67 

"    ■    «  "  at  the  shoulder,  Part  IV,  Chapter  II 

"  of  the  tendo  Achilles  forward,  161-162 

"     "        "  "    one-half  forward,  160,  161, 

162 
"         "        "  "  of  the  tensor  fascia-femoris,  61-67 

at    "   thigh,  61 
"         "         "  "  of    "         "     plaster  of  Paris,  68 

"         "         "  "  "     "   tibialis  anticus,  paralysis,  148-160 

"         "         "  "  "     "  "  "       in  paralysis  of  the  exten- 

sor hallucis,  166 
"         "         "  "  of  the  tibialis  posticus,  151,  also  167 

"         "  "  "     "  "    .         "       forward,  151 

"  "     "  "  "       to   the  tendo  Achilles, 

164 
"  for  toe  drop  fascia,  178 

"         "         "  "  of  the  trapezius  to  the  deltoid,  219 

,(         "  "  "     "  "       "     "    pectoralis  major,  220 

"     "   triceps,  250 
"         "         "  "  "     "        "       to  the  biceps,  250 

"         "         "  "  two  hamstrings  forward  in  the  thigh,  62 

"         "         "  "  "     "   wrist,  284,  also  Part  VI,  Chapter  II,  see 

deformities,  muscle  and  tendon  operations  under  each  joint,  paralysis 
Myotomy,  adductors,  of  the,  69 
"         hamstrings,  of  the,  69 
"         in  obstetrical  paralysis,  208 
"        in  spastic  paralysis,  71 


N 

Neck  deformity,  see  wry  neck,  torticollis 

"      of  the  femur,  fracture,  28 

"       "     "       "        osteotomy  for,  39 

"       "     "       "        fracture  or  osteotomy,  plaster  of  Paris' bandage  for,  326 
Nerve,  sciatic  incision  for,  30 

"      supply  of  the  muscles  of  the  forearm,  296 
Normal  motions  of  the  shoulder,  202 


o 

Ober  operation  for  club  foot,  106 
Obstetrical  paralysis,  208 

"  "        Sever  operation,  208 

"  "        depression  of  the  acromion,  211,  see  shoulder  inward  rotation 


INDEX  339 

Olecranon  fracture,  267 
Ollier's  incision  at  the  wrist,  298 

"       method  of  excision  at  the  wrist,  311 
Operations  in  infantile  paralysis,  general  considerations,  319,  see  muscle  and  tendon 

operation,  deformities 
Operations  in  the  neck,  wry  neck,  314 
Oscalcis,  disease  of  the,  195 

"       tilting  in  club  foot,  104,  105,  106,  107 
"  "     "   flat  foot,  112 

"  "      "   valgus,  112 

Osgood's  instrument  in  hallux  valgus,  125 
Osgood  operation  at  the  knee,  59 
Oste-ectomy,  see  deformities 
Osteo-arthritis  at  the  hip,  arthrodesis  for,  40 
Osteomyelitis,  see  suppurative  conditions  of  the  hip,  knee,  ankle,  shoulder,  elbow  and 

wrist,  also  323 
Osteomyelitis,  ankle,  198,  323 

"  elbow,  275,  323,  see  suppurative  conditions  at  the  elbow 

"  fibula,  97,  98,  99,  323 

hip,  43,  44,  45,  also  323 
"  humerus,  242-244,  323 

"  knee,  97,  98,  99,  also  323 

"  plastic  operation  for  closing  wounds  from,  200 

radius,  see  suppurative  conditions  about  the  elbow,  also  sections  275, 
323 
"  shoulder,  242-244,  also  323 

"  suppurative  conditions  at  the  hip,  323,  see  under  each  joint 

"  tibia,  97,  98,  99,  also  323 

"  ulna,  see  suppurative  conditions  about  the  elbow,  also  275,  323 

"  wrist,  Part  VI,  Chapter  V,  also  323 

Osteotome,  good  and  poor,  Figs.  494-498 
Osteotomy,  188 

"         for  anterior  bow  legs,  53 
"    bow  leg,  53 
"     coxa  vara,  29 
"  "     depressed  acromion,  205 

"  "     femur,  55 

"  "     flexion  deformity  of  the  hip,  6,  8,  37 

"  "     flexion  deformity  of  the  knee,  54 

"  "     hallux  valgus,  125 

"     hip,  37 
"  "     hip,  plaster  of  Paris  after,  332 

"  "     inward  rotation  of  the  shoulder,  204 

"  "     knee  deformity,  55 

"  "     knock  knee,  53 

"  "     metatarsal,  123 

"  "     neck  of  the  femur,  39 

"  "     shoulder  inward  rotation,  204 

"  "     subtrochanteric,  37 

"  "     trochanteric,  36 

Overhead  sling  after  operation  on  the  arm,  273 
Overlapping  fractures  of  both  bones  of  the  forearm,  266 
"  "        "  elbow,  263 

"  "         "  hip,  method  of  treating,  26 

"  humerus,  263 
"  "         "   shoulder,  236 


340 


INDEX 


Paralysis  of  the  abductors,  silk  ligaments  at  the  hip  for,  13 

•  ankle,  168,  171,  174,  see  Chapter  III 

'  anterior  thigh  muscles,  61-67 

'  biceps;  transplantation  of  the  triceps,  222,  also  251 

'  deltoid;  transplantation  of  the  pectoralis  major,  221 

'  "    "                    "             "       "             "             "     to    the     trapezius, 

220 

"  "  to  the  trapezius,  219 

'  "                    "            of  the  trapezius  to  part  of  the  pectoralis 

major,  220 

'  elbow,  222,  251,  Part  V,  Chapter  III,  also  251,  252,  253 

'  extensor  of  the  great  toe;  transplantation  for,  166 

'  "        longus  digitorum;  transplantation  for,  292 

'  "             "             "                         "              of  the  palmaris  longus, 

291 

"  "  "  "  for,  292 

'  "             "             "                    "             of  the  palmaris  longus,  291 

'  flexor  longus  digitorum,  muscle  transplantation  for,  293 

'  "           "     pollicis,  muscle  transplantation  for,  293 

'•'  "          "             "      when  the  flexor  carpi  radialis  is  spared,  294 

'  flexors  of  the  wrist,  transplantation  of  the  extensor  carpi  radialis,  295 

;<  "      "    "       "        transplantation  of  the  flexor  carpi  ulnaris,  295 

:<  foot,  astragalo-scaphoid  arthrodesis  for,  114 

'  hip,  11-12 

'  "    abductors,  silk  ligament  for,  13 

'  "    arthrodesis  for,  12 

'  "    fasciotomy,  8 

:<  "    silk  ligaments  for,  13 

'  "    Soutter  operation,  8 

"  "    transplantation  of  the  hip  flexors,  8 

:'  knee,  77 

'  "    arthrodesis,  75 

"  "    Bartow  silk  ligament  for,  77 

;'  "    silk  ligaments,  77 

"  "    operations  for,  Part  II,  Chapter  III 

"  "    hamstring  transplantation,  61,  62 

"  "    sartorius  transplantation,  63 

"  "    tensor  fascia  femoris  transplantation,  64 

"  peroneii,  transplantation  of  one-half  of  the  tendo  Achilles,  161 

"  quadriceps,  muscle  transplantation,  61 

"  "         hamstring  transplantation,  61,  62 

"  "         sartorius  transplantation,  63 

"  "         tensor  fascia  femoris  transplantation,  64 

"  shoulder,  218,  222,  also  see  Chapter  III,  Section  IV 

"  "       arthrodesis  for,  225 

"  "       with  depressed  acromion,  224 

dislocation,  214 

"  "       silk  ligaments  for,  226 

"  "       transplantation  of  the  pectoral,  220 

"  "                      "             "     "  trapezius,  219 

"  "       see  deltoid  paralysis 

"  tendo  Achilles,  transplantation  of  the  flexor  longus  digitorum,  163 

"  "             "                    "             "      "  peroneii,  165 

"  "  "  "      "  tibialis  posticus,  164,  167 


INDEX  341 

Paralysis  of  the  tibialis  anticus,  muscle  transplantation  for,  148-160 

"        "     "  "  "       transplantation  of  the  extensor  hallucis,  157 

"     "  "  "  "  "     "  "       digitorum,  156 

"     "  "  "  "  "     "   peroneii,  165 

"        "     "  "  "  "  "     "    tibialis  posticus,  151 

"        "     "  "  "  "  "     "   tendo  Achilles,  160 

"        "     "  "  "  "  of  one-half  of  the  tendo  Achilles 

forward,  162,  see  also  under  deformities  of  each  joint  due  to  paralysis 
Paralysis  spastic,  myotomy  for,  69,  71 
Paralytic  dislocation  of  the  ankle,  see  flail  ankle 

"  "     "    hip,  see  arthrodesis,  silk  ligament 

"  "  "     "    knee,  see  arthrodesis,  silk  ligament 

"  "  "     "    shoulder,  partial  dislocation  of,  211-212,  also  223 

Patella  dislocation,  92 

"     fracture,  90 
Pectoralis  muscle,  tenotomy,  208 
Periosteal  needle,  Figs.  91,  281 
Peroneii  transplantation,  148 
"       after  treatment,  150 
"       Lange  method,  148 
"       post-operative  plaster,  149 
"       tenotomy  of  the,  138 
Pes  cavus,  116 

Phalangeal,  see  metacarpal,  metatarsal 
Pig's  bladder  for  arthroplasty,  95 
Plaster  of  Paris,  Albee  operation,  see  plaster  shell 
"       "         "     ankle,  Figs.  451-456 

"       "         "     ankylosis  of  the  spine  operation,  see  plaster  shell 
"       "         "     astragalectomy,  170 
"       "         "     calcaneus,  338 
"       "         "     calcaneo  varus,  337 
"       "         "  "        valgus,  338 

"       "         "     club  foot,  337  also  Figs.  457-458 
"       "         "     cuirass,  Figs.  318,  320 

"       "         "     deformities  of  the  foot,  121,  also  see  chapter  on  deformities  of  the  foot 
"       "         "     elbow,  249 
"       "         "     for  equino  varus,  337 
"       "         "       "  equino  valgus,  338 
"       "         "       "  equinus,  131 
"       "         "       "flat  foot,  338 
"       "         "       "  fasciotomy,  332 
"       "         "       "  fracture  of  the  hip,  37,  329 
"       "         "       "         "         "  both  bones  of  the  forearm,  266 

"       "  following  operations,  see  under  each  operation 
"       "         "       "  foot,  457-458 
"       "        "       "       "    deformities,  457-458 
"       "         "       "       "    manipulation,  131 
"       "         "       "       "    operations,  131,  also  336 
"       "         "       "  Gant  operation,  10 
"      "        "      "hip,  Section  330  also  Fig.  450 
"       "         "       "     "    congenital  dislocation,  5 
"       "         "     hip,  congenital  dislocation  in  the  after  treatment,  3 
"       "         "       "     dislocation,  5 
"       "         "       "     in  infantile  paralysis,  10 
"       "         "     head,  326 
"       "         "     Hibbs  operation,  see  plaster  shell 


342 


INDEX 


Plaster  of  Paris  jacket,  327 

"      "        "  "      portable  frame  for,  Fig.  469 

"      "        "     knee,  56-57 
"       "         "         "     manipulation,  56,  also  335 
"      "        "        "     operation,  56,  also  334 
"      "        "     knife,  for,  Fig.  462 
"       "         "     lacing  method  of,  325 
"      "        "     leg,  Fig.  461,  also  Section  335 
"       "        "     method  of  lacing,  325 
"       "         "     method  of  preventing  rotation,  58 
"       "        "     muscle  transplantation  of  the  hip  flexors,  8-10,  332 
"      "        "  "  "  in  the  thigh,  68 

"      "        "     neck,  326 
"       "         "     ropes,  326 
"       "        "     posterior  shell,  463 
"      "        "     sheU,  Figs.  463^66 
"       "        "        "     posterior,  Fig.  463 
"       "         "     shoulder,  217,  also  328,  Figs.  459-460 
"       "         "     spica  board,  Figs.  467-468 
"       "         "     Soutter  operation,  332 
"       "         "     spine,  see  posterior  shell,  jacket 
"       "         "     thigh,  muscle  transplantation,  68 
"       "         "     thorax,  326 
"       "         "     toe  operation,  339 
"       "         "     trochanter  operation,  10 
"       "         "     varus,  337 
"      "        "     valgus,  338 
"       "         "     see  also  under  each  operation 
Plastic  operation  on  the  spine,  320 
"      Albee,  321 
"      Hibbs,  322 
Poliomyelitis,  see  deformities,  muscle  and  tendon  operations,  muscle  transplantation 
"  general  considerations,  319 

"  "      principles,  319 

Post-operative  treatment,  see  under  each  operation 
Posterior  incisions,  see  incisions 
"        plaster  shell,  Fig.  463 
Potts  disease,  operation  on  the  spine,  320,  321,  322 

"    fracture  deformity,  117 
Preparation  of  the  skin  for  operation,  340,  see  Part  VII,  Chapter  III,  also  340-347 
"     "       "     "  "        arm,  343 

"    "      "     "  "        elbow,  345 

"     "       "     "  "        foot,  341 

"     "       "     "  "        forearm,  346 

"     "       "     "  "        hand,  346 

"     "      "     "  "        hip,  347 

"     "       "     "  "        knee,  341-342 

"     "       "     "  "        leg,  341 

"     "       "     "  "        shoulder,  344 

"     "       "     "  "        thigh,  347 

Puncture,  ankle,  Part  III,  Chapter  IV,  also  191 
"        elbow,  268 

hip,  33 
"        knee  joint,  Part  II,  Chapter  IV,  also  Section  93 
"        shoulder,  Part  IV,  Chapter  IV,  238 
"        wrist,  305 


INDEX  343 

Q 

Quadriceps  rupture,  60 

R 

Rachitic  deformity,  317,  see  osteotomy,  rickets,  317 
Radius  bowing,  266 
"       deformity,  266 
"       fracture  of  both  bones,  263,  266 
"  "        overlapping,  263,  266 

"       osteomyelitis  of,  see  suppurative  conditions  about  the  elbow,  also  275 
"       suppurative  conditions,  275 
"       synostosis,  270 
Recumbent  frame,  Figs.  8,  9,  10,  24 
Retaining  apparatus  for  the  hand  post  operative,  333 
"  "  "     "   wrist  post  operative,  333 

Ruptured  muscle,  60 

"       quadriceps,  60 

S 
Sacro-iliac  joint,  15 

"      "    incision,  15 
Sartorius  muscle  transplanted,  65 
Scapula  deformity,  216 

"        suppurative  conditions,  45,  also  323 
Sciatic  nerve,  incision  for  exposure,  30 
Semilunar  cartilage,  incision  for  exposure  of,  78 
Semimembranosis,  see  hamstring 
"  myotomy,  69 

"  "  transplantation,  61-67 

Semitendonosis,  see  hamstring 
"         myotomy,  69 
"  "         transplantation,  61-67 

S'ever's  operation,  208 

Silk  elongation  for  cut  tendon  in  the  hand  or  finger,  282 
"  "  short  tendon  in  the  hand  or  finger,  282 

"  ligaments,  13,  77,  171,  172,  173,  226 
ankle,  171,  172,  173 
hip,  13 
"  "  knee,  Bartow,  77 

"  open  method,  172 

"  "  in  paralysis  at  the  knee,  77 

paralysis  of  the  shoulder,  226 
"  shoulder,  226 

subcutaneous  method,  173 
"  "  for  toe  drop,  171,  172,  173 

"  "  for  weak  ankle,  171,  172,  173 

Skin  operation,  for  flail  elbow,  254 

"         at  the  elbow,  Jones  operation,  254 
"   preparation  for  operation,  347 

arm,  343 
elbow,  345 
foot,  341 
hand,  346 
knee,  341-342 
leg,  341 
shoulder,  344 
Shell,  plaster  of  Paris,  Figs.  463,  466 


344  INDEX 

Shoe  stiffening,  Fig.  479 
Short  tendon  of  the  finger,  2S2 
Shoulder,  acromion  depressed,  224 

ankylosis,  arthroplasty  for,  241 

anterior  incision,  228 

arthrodesis,  225 

arthroplasty,  241 

arthrotomy,  anterior  incision,  228 

enlarged,  229 
Burrell         "         213 
Codtnan       "         231 
Kocher         "         230 
"  posterior      "         229 

Bartow  silk  ligament  for,  226 
capsulorrahphy,  214,  also  224 
deformity  from  fracture,  237 
depressed  acromion,  224 
dislocation,  irreducible,  213,  also  215 

"  and  depressed  acromion,  211,  224 

"  paralytic,  212,  also  223 

partial,  212 
excision,  239-240 

"         partial,  239 
excisions  in  suppurative  conditions,  244 
flail  shoulder,  223 
fractures,  232-237 

"         deformities,  237 
"         humerus,  232-237 
"         overlapping,  236 
"         ununited,  237 
fracture,  traction  apparatus  for,  Figs.  375,  378 

"       ununited,  237 
incision,  228-231 

Codman,  231 
Kocher,  230 
infantile  paralysis  of,  see  deformities,  muscle  transplantation,  paralysis 
inward  rotation  of  the,  muscle  lengthening  for,  207 
"      "  "     shortening  for,  206 

"      "    myotomy  for,  207-209 
"  "         "      "    obstetrical  paralysis  cases,  208 

"  "         "      "    osteotomy  for,  204 

"  "         "      "    Sever  operation  for,  208 

manipulation  of,  202 

muscle  lengthening  for  inward  rotation  of,  207 
"    operations,  Part  IV,  Chapter  II 
"    shortening  for  inward  rotation  of,  206 

"    transplantation,  see  under  paralysis  and  under  muscle  transplanta- 
tion 
myotomy  for  inward  rotation,  207-209 
obstetrical  paralysis  with  inward  rotation  of  the,  208 
osteotomy  of  the  acromion,  205  ; 

"        "     "    humerus,  204 
"        for  inward  rotation,  204 
osteomyelitis,  242-244,  also  323 
paralysis,  arthrodesis,  225 
plaster  of  Paris  for,  217,  also  328,  Figs.  459-460 


INDEX  345 

Shoulder,  poliomyelitis,  see  deformity,  paralysis,  muscle  transplantation 
"         posterior  incision,  229 

"         rotation  in,  of  the;  muscle  lengthening  for,  207 
"  "         "     "     "  "       shortening  for,  206 

"  "         "  v«     "     myotomy  for,  207-209 

"  "         "     "     "     obstetrical  paralysis  cases,  208 

"         •     "         "     "     "     osteotomy  for,  204 
"  "         "     "     "     Sever  operation  for,  208 

"         Sever  operation  for  the,  Figs.  314,  315 
"         silk  ligaments,  226 
"         splint  of  wire  for,  Figs.  314,  315 
"         suppurative  conditions,  242,  244,  also  323 
"         tapping,  238 

"         tendon  operations,  Part  IV,  Chapter  II 
"  "      transplantation,  Part  IV,  Chapter  II 

"         traction  apparatus  for,  235 
wire  shelf  for,  Figs.  314,  315 
Solution  for  Carrell  technique,  323 
"        "   Dakin  technique,  323 
"        "   injection  into  the  joint;  Murphy's,  238 
Soutter  operation,  transplantation  of  the  hip  flexors,  8 
Spastic,  myotomy,  69-70 
"      paralysis,  71-73 
"  "  fasciotomy  for,  8 

"  "  myotomy  for,  71 

"  "  inward  rotation  of  the  shoulder  for,  209 

"  "  tendon  lengthening  for,  127 

tenotomy  for,  33,  71,  127,  283 
Spica  board  for  plaster  of  Paris,  Figs.  463,  467,  468 
Spinal  ankylosis,  Hibbs  operation,  322 
"      operation,  after  treatment,  322 

"      tuberculosis:  operative  ankylosis  of  the  spine  for,  321,  322 
Spine  operative  to  obtain  ankylosis  for,  320,  321,  322 
"         "     Albee  operation,  320-321 
"  "        "        "     Hibbs  operation,  320-322 

Spint,  see  apparatus 
Splitting  the  patella  laterally,  82 
Sprengle's  deformity,  216 

"       incision  for  exposure  of  the  ilium,  14 
Stiff  ankle  following  Potts  fracture,  117 
Subcutaneous  tenotomy,  132 

"  "         of  the  tendo  Achilles,  128  also  132 

Subluxation  of  the  knee,  51 

"  "     "         "   correction  with  genuclast,  51 

"     "         "   manipulation  for,  51-52 
"  "     "    tibia  operative  treatment,  51 

Subperiosteal  club  foot  operation,  106 
flat  foot  operation,  112 
lengthening  of  the  hip  flexors,  8 
operation  for  tendon  lengthening  in  the  forearm,  286 
"       on  the  elbow,  272,  276 
"     "    wrist,  307,  311 
"  tendon  insertion,  Vulpius,  150 

Subscapulars  tenotomy,  208 
Subtrochanteric  osteotomy  at  the  hip,  37 
Support  for  the  ankle,  see  braces  and  Figs.  477,  479,  480 


346 


INDEX 


Suppurative  conditions,  323,  see  also  under  each  joint 

"  "  of  the  ankle,  194-201,  also  323 

"  "     "   bone,  323,  see  also  under  each  joint 

"  "     "    Carrcll-Dakin  technique,  323 

"  "     "   compound  fractures,  see  under  each  bone  and  323 

"  "  "     "   elbow,  274-277  and  323 

"     "  fingers,  312 
"     "   foot,  194,  201,  323 

"  "  "     "   hand,  309,  311,  323 

11  "  "     "   hip,  43,  44,  45,  also  323 

"  "  "     "   knee,  96,  97,  98,  99,  also  323 

"  "  "    "   metatarsal,  196 

"  "  "    "   oscalcis,  195 

"  "     "   phalanges  of  the  foot,  196 

"  "  "     "   scapula,  245,  also  323 

"  "  "     "   shoulder,  242-244,  also  323 

"     "   tarsus,  195 
"     "   toes,  196 

"  "  "     "   wrist,  309,  310,  also  323 

"  "  "     "   wrist,  excision,  311 

Suppurating  wounds,  Carrell  operative  method  of  preparation,  323J 
Synostosis  of  the  elbow,  270 


Tapping  the  ankle,  191 

"  "   elbow  joint,  268 

"  "  hip  joint,  33 

"  "  knee  joint,  93 

"  "  shoulder,  238,  also  Part  IV,  Chapter  IV 

"  "   tarsus,  195 

"  "   wrist  joint,  305 

Tarsal,  tuberculosis,  197 
Tarsus,  bone  operation,  see  pes  cavus,  club  foot  and  valgus 

"     suppurative  conditions,  195  and  323 
Tendo  Achilles,  see  under  muscle  transplantation,  deformity,  paralysis 
"  "      shortening,  146 

"  "      subcutaneous  tenotomy,  128,  132 

"  "      zig-zag  tenotomy,  132 

Tendon  carrier,  Fig.  80,  also  230 
"      cut,  of  the  finger,  282 
"         "    silk  elongation,  282 
"     fixation,  174,  175,  176,  177 

"       ankle,  174-177 
"  "       calcaneus,  177 

"       Galli,  174-177 
"  "       valgus,  176 

"  "       varus,  175 

"      elongation  in  the  finger,  282 
"      insertion,  Vulpius,  150 
"      lengthening,  126-133 

extensors  of  the  fingers,  285 
"  "  •   "         "     "   wrist,  285 

"  "  flexors  of  the  fingers,  287-288 

"     "      "  wrist,  287-288 
"  "  hamstring,  69-70 

"  "  knee,  50 


INDEX  347 

Tendon  lengthening,  knee  flexed,  50 

"  "  open  operation  for,  127 

"  "  peroneii,  138 

"  "  in  spastic  paralysis,  71-73,  127,  283 

"  "  subperiosteal  operation  at  the  elbow,  286 

"  "  tenotomy,  127-132 

"  thigh,  69-70 

"  "  tibialis  anticus,  139 

"  "  "      posticus,  137 

"      operations,  see  Chapter  II,  deformities,  paralysis,  transplantation,  tendon 
fixation,  silk  tendons 
Tendon  operations,  elbow,  Part  V,  Chapter  II 
"  "  finger,  Part  VI,  Chapter  II 

"  "  foot,  Part  III,  Chapter  II 

"  hip,  Part  I,  Chapter  II 

"  "  knee,  Part  II,  Chapter  II 

"  "  tenosynovitis,  315 

"  "  wrist,  Part  VI,  Chapter  II 

"      shortening,  see  tendon  operations 

Achilles  tendon,  146 
"  "  extensors  of  the  fingers,  290 

"  "  extensor  longus  digitorum,  147 

"  "  extensors  of  the  wrist,  290 

"  "  flexors  of  the  fingers,  289 

"  "  "     "      "  wrist,  289 

"  "  leg,  144-145 

"  "  long  flexors  of  the  fingers,  289 

«  "  «        «      "    "  wrist,  289 

"  tendo  Achilles,  146 

Tenotome,  the,  133,  also  Figs.  208-209 
"     bad,  133 
"     good,  133 
"  "     selection  of,  133 

Tenosynovitis,  315 

Tenotomy,  see  deformities,  see  paralysis 
"         adductor  magnus,  of  the,  74 
"         extensor  longus  digitorum,  of  the,  119-121 
"         general  principles  of,  126-133 
"         hamstrings,  of  the,  69-70 
"         hammer  toe,  118-124 
"         lengthening  a  tendon,  128 
"         obstetrical  paralysis  for,  208 

"         open,  for  short  flexor  longus  digitorum  in  the  leg,  134 
"         pectoralis  muscle,  of  the,  208 
"         peroneii,  138 
"         planta  fascia,  136 
"         spastic  paralysis,  71,  73,  127,  283 
"         subcutaneous  at  base  of  the  toes,  135 
"         subscapularis,  208 
"         tibialis  anticus,  139 
"  "     posticus,  137 

"  "toe  deformity,  118-124 

Testing  Carrell  solution,  323E 

"      chloride  of  lime  for  chlorine,  323C 
"      Dakin  solution,  323E 
Tempo-maxillafy  arthroplasty,  318 


34S  INDEX 

Thomas  club  foot  wrench,  101 
"  wrench,  Figs.  121-130 
"  "       manipulation  of  the  foot,  101 

Thorax,  plaster  of  Paris  bandage  for,  326 
Tibia  bowing,  53 
"      deformity,  53 
"      fracture,  117 

fracture  overlapping,  189 
"      osteotomy,  53 
"      subluxation,  51 
"      suppurative  conditions,  194,  323 
Tibialis  posticus,  tenotomy,  137 
Tibio-tarsal  arthrodesis,  179 
"  "     arthroplasty,  193 

"  "     flail  joint,  see  astragalectomy 

Tilting  of  the  oscalcis  in  club  foot,  104-107,  112 
Toe,  apparatus  for  the,  Figs.  190-193 
"   ankylosis,  see  hammer  toe 

"   arthroplasty,  see  finger  arthroplasty,  hammer  toe  operation 
"    arthrotomy,  125 
"    contracted,  118-124 
"   deformity,  124 

"  "         excision  of  the  joint,  124 

"   hallux  valgus,  125 
"   hammer  toe,  118-124 
"  "       bone  operation  for,  123 

"  "       excision  for,  124 

"       manipulation,  99,  118 
"  "       tenotomy  operation  for,  120,  121,  122 

"    drop,  silk  ligaments  for,  171-173 
"   plaster  of  Paris,  after  operation,  339 
Torticollis,  myotomy,  314 

"         plaster  of  Paris,  326 
Traction  apparatus  for  operations  on,  Figs.  54-61 
"  "  arm,  262 

"  "  "  congenital  hip,  2 

"  elbow,  262 
"  "  "  fractures  of  the  elbow,  262 

"  "  "  "         "     "  femur,  Figs.  54-57 

"     "  hip,  37,  Figs.  54-57 
"  "  "  "         "     "  humerus,  235 

"  "  "        "     "  knee,  Figs.  54-57 

"     "  shoulder,  235,  Figs.  375-378 
"     "   tibia,  Figs.  54-57 
"  hip,  37,  Figs,  54,  55,  56,  57 
"  "  "  humerus,  235 

"  leg,  Figs.  54-57 
"  shoulder,  235 
"        machine,  see  traction  apparatus 
Treatment  of  overlapping  fractures,  see  fractures 
Tuberculosis  of  the,  see  suppurative  conditions 
"     "     ankle  and  foot,  197 
"         "     "     elbow,  excision,  276 

"         "     "     hand,  see  suppurative  conditions  of  the  wrist 
"         "     "     spine  operation  for  obtaining  ankylosis,  321,  322 
"         "     "     wrist,  see  suppurative  conditions  of  the  wrist,  excision 


INDEX  349 

U 

"U"  shaped  incision  anterior,  at  the  hip,  23 
"      at  the  hip,  22 
"         "  "      knee,  86 

Ulna  bowing,  317 
"    deformity,  317 
"    fracture,  overlapping,  266 
"    osteotomy,  see  osteotomy  for  bow  legs,  53 
"     suppurative,  274-277 
Ununited  fractures,  see  fractures 

V 

Valgus,  109-114 

"       after  treatment,  for,  113 

"       astragalo-scaphoid,  arthrodesis,  114 

"        bone  operation  for,  111 

"       manipulation,  see  deformity,  paralysis,  muscle  transplantation 

"       plaster  for,  113,  see  foot  wrenches 

"       plaster  of  Paris  bandage  after  operation,  338 

"       tendon  fixation,  176 

"       tilting  of  the  oscalcis  in,  112 

"       transplantation  of  the  peroneii,  148 
Varus,  see  deformities,  manipulation  of  the  foot,  foot  wrenches,  paralysis,  muscle 
transplantation,  also  104-108 

"      after  treatment,  108 

"      application  of  plaster,  107 

"     bone  operation  for,  105 

"      operations  for,  104-107 

"      plaster  of  Paris  for,  337 

"      tendon  fixation,  175 
Vulpius,  subperiosteal  tendon  insertion,  150 

W 

Whitman's  operation,  168,  also  see  astragalectomy 

"         treatment  of  fracture  of  the  neck  of  the  femur,  28 
Wrench  for  club  foot,  Bradford's,  Figs.  145,  150,  also  135-141 
"      Bradford's  for  foot  manipulation,  102 
"      Davis'  for  foot  manipulation,  103 
"      Thomas  for  foot  manipulation,  Figs.  121-134 
Wrist,  ankylosis,  arthroplasty  for,  307 
"  "        excision  for,  311 

"      anterior  incision,  300 
"     apparatus  after  operation,  on,  333 
"     arthroplasty  for  ankylosis,  307 
"     arthrotomy,  297-304 
"  "  anterior  incision,  300 

"  "  external  incision,  301 

"  "  metacarpal  incision,  302 

"  "  Oilier  incision,  298 

"  "  posterior  incision,  299 

"  "  radial  incision,  301 

"      club  hand,  279 
"     congenital  deformity,  278-280 
"     contracted  fingers,  280 
"         tendons,  280 
wrist,  280 


350  INDEX 

Wrist,  cut  tendons,  2S2 

"  deformity,  Part  VI,  Chapter  I 

"  "         club  hand,  279 

"  "         Madelung,  27S 

"  "        pronation,  2S3 

"  "         Tubby  operation  for,  283 

"  "         wrist  manipulation  for,  281 

"  dislocation,  278 

"  excision  of  the  carpus,  311 

"  "      for  ankylosis,  311 

"  "      in  suppurative  conditions,  311 

"  external  incision,  301 

"  flexed,  2S0 

"  flexors  contracted  tendon  lengthening  subperiosteal^  at  the  condyle,  288 

"  fractures,  carpal,  303-304 

"  incisions,  anterior,  300 

"  "        external,  301 

"  "        metacarpal,  302 

"        Oilier,  298 

phalangeal,  302 

"  "        posterior,  299 

radial,  301 

"  infantile  paralysis,  see  deformities,  muscle  transplantation,  deformities,  muscle 

and  tendon  operations 

Wrist,  manipulation  for  the,  281 

"  Madelung  deformity,  278 

"  osteomyelitis,  Part  VI,  Chapter  V,  323 

"  poliomyelitis,  see  paralysis,  deformities,  muscle  transplantation 

"  preparation  of  the  skin  for  operation,  346 

"  pronation  deformity,  283 

"  pronation  deformity,  muscle  transplantation,  Tubby  operation  for,  283 

"  puncture,  305 

"  retaining  apparatus,  333 

"  ricketic  deformity,  317 

"  silk  extension  for  cut  tendons,  282 

"  suppurative  conditions,  Part  VI,  Chapter  V,  323 

"  tendon  elongation,  282 

"  "       lengthening,  285 

"  tapping  the,  305 

"  "       shortening,  289-290 

"  "       silk  extension,  282 

"  tendons  cut,  282 

"  Tubby  operation  for  pronation  of  the,  283 

"  tuberculosis,  see  suppurative  conditions 

"  wry  neck,  314 


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Deformities,  Including  Diseases  of  the  Bones 
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Tuberculosis    of    the    Bones    and    Joints    in 
Children 

BY  JOHN  FRASER,  M.D.,  F.R.C.S.E.,  Ch.M., 

Assistant  Surgeon,  Royal  Hospital  for  Sick  Children,  Edinburgh 
With  51  full  page  plates  (2  in  color)  and  164  figures  in  the  text 

Royal  Svo,  352  pp.,  index,  -$4.50 

Tuberculous  Disease  of  the  Bones  and  Joints  is  in  large 
measure  a  disease  of  children,  and  as  a  result  of  the  dis- 
astrous consequences  which  so  often  follow  its  course,  it 
is  one  of  the  most  important  of  the  various  forms  of  Tuber- 
culosis. This  work  deals  fully  with  the  condition.  The 
more  recent  investigations  on  the  Etiology  are  fully  dis- 
cussed, the  Pathology  is  a  special  feature,  and  much  of  the 
material  in  this  relation  is  original.  Diagnosis,  Prognosis 
and  Treatment  are  fully  discussed.  Special  attention  has 
been  paid  to  the  making  and  fitting  of  the  various  splints. 

Dr.  Fraser  is  well  known  to  American  physicians  through 
his  various  magazine  contributions  and  lectures.  His  book 
is  without  doubt  one  of  the  most  important  publications 
that  has  yet  appeared  on  this  subject. 


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Technique  of  operations  on  the  bones 
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